December 2009, Volume 59, Issue 12

Letter to the Editor

Cardiac Revascularization: CABG vs PTCA

Madam, Coronary artery disease (CAD) is the leading cause of all the cardiovascular related morbidities and mortalities worldwide. As many as 4.5 million people in the developing world die of CAD each year. South Asians have the highest susceptibility to atherosclerosis making them most vulnerable to CAD related mortalities worldwide.1
Coronary Artery Bypass Grafting (CABG) and Per Cutaneous Transluminal Coronary Angioplasty (PTCA) though invasive, are by all means more effective and superior to the conventional medical therapy for the management of Myocardial Infarction (MI) patients. Primary PTCA is an emergency measure for the management of acute MI whereas CABG being a surgical procedure requires extensive pre operative preparation and cannot be used as a measure for acute management of MI.
Over the years many randomized trials have been carried out around the world indicating the long-term survival rates of both CABG and PTCA depending upon the anatomical site and extent of the disease. Although 20 year survival of CABG and PTCA is the same, the 3 year survival rate for patients undergoing PTCA for a single vessel CAD with no or insignificant (less than 70%) LAD blockage has been 2.9% better than those undergoing CABG. On the contrary, CABG proved superior to PTCA in terms of the 3 year survival rate of patients having either three vessels CAD or proximal LAD stenosis of more than 70%.2 CABG being the more invasive procedure has longer recovery period, however, it is still the treatment of choice for patients requiring simultaneous valvular replacement.
A study carried out in United States and Canada demonstrated that as many as 54 % of patients undergoing PTCA had at least one re-hospitalization in 5 years after the initial procedure compared to only 8 % re-hospitalization in patients who had undergone CABG over the same period.3 The primary cost of CABG has been reported to be 53% higher than PTCA, however, the gap closes down to less than 5 % during the first two years due to the post-treatment morbidity associated with PTCA.4
In the setting of restenosis following PTCA in small vessels, diffuse narrowing and diabetes, drug eluting stents are being used with favorable results.5 As a result of this in the recent past, there has been a significant change in clinical management of patients from surgical to percutaneous revascularization.
Faran Salim Polani, Syed Muhammad Ali Saad
Class of 2011
Dow Medical College, Karachi, Pakistan.

References

1.Bainey KR, Jugdutt BI. Increased burden of coronary artery disease in South-Asians living in North America. Need for an aggressive management algorithm. Atherosclerosis 2009; 204: 1-10.
2.Hannan EL, Racz MJ, McCallister BD, Ryan TJ, Arani DT, Isom OW, et al. A comparison of three-year survival after coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 1999; 33: 63-72.
3.The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 1996; 335: 217-25.
4.Hlatky MA, Boothroyd DB, Melsop KA, Brooks MM, Mark DB, Pitt B, et al. Medical costs and quality of life 10 to 12 years after randomization to angioplasty or bypass surgery for multivessel coronary artery disease. Circulation 2004; 110: 1960-6.
5.Ferreira AC, Peter AA, Salerno TA, Bolooki H, de Marchena E. Clinical Impact of Drug-Eluting Stents in Changing Referral Practices for Coronary Surgical Revascularization in a Tertiary Care Center. Ann Thorac Surg 2003; 75: 485-9.

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