Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Coronary angioplasty and bypass surgery for coronary artery disease had similar rates of death and nonfatal MI at 2.5 years

ACP J Club. 1993 Sept-Oct;119:40. doi:10.7326/ACPJC-1993-119-2-040


Source Citation

RITA Trial Participants. Coronary angioplasty versus coronary artery bypass surgery: the Randomised Intervention Treatment of Angina (RITA) trial. Lancet. 1993 Mar 6;341:573-80.


Abstract

Objective

To compare the effectiveness of percutaneous transluminal coronary angioplasty (PTCA) with coronary artery bypass surgery (CABG) in patients with 1 to 3 diseased coronary arteries.

Design

Randomized controlled trial with a mean follow-up of 2.5 years.

Setting

16 hospitals in the United Kingdom.

Patients

1011 patients (median age 57 y, 81% men) with 1 to 3 arteriographically proven diseased coronary arteries in whom equivalent revascularization was achievable by either PTCA or CABG. Exclusion criteria were left main-stem disease, previous PTCA or CABG, valve disease, or a noncardiac disease limiting long-term prognosis.

Intervention

510 patients were assigned to PTCA and 501, to CABG. Medication during and after the procedure was administered at the discretion of the attending physician.

Main outcomes measures

Death and nonfatal myocardial infarction (MI). All other major cardiovascular events and hospitalizations were documented.

Main results

Intention-to-treat analysis was used. CABG and PTCA procedures were done in 490 (98%) and 493 (97%) patients, respectively. All selected vessels were grafted during CABG. Dilatation was attempted in 87% of treatment vessels in PTCA patients with a per vessel success rate of 87%. 34 patients died, 18 (4%) in the CABG group and 16 (3%) in the PTCA group. 26 CABG patients (5%) had a nonfatal MI compared with 34 PTCA patients (7%). No evidence was found of a difference between CABG and PTCA for the combined end points of death and MI (relative risk 0.88, 95% CI 0.59 to 1.29, P > 0.2). Within 2 years of randomization, 38% of PTCA patients had further CABG, PTCA, or MI, or had died, compared with 11% of CABG patients (P < 0.001). 157 PTCA patients (31%) and 37 CABG patients (7%) had ≥ 1 repeated coronary arteriograms during follow-up (P < 0.001). 2 years after randomization, the prevalence of angina was 22% for CABG patients compared with 31% for PTCA patients (P = 0.007). PTCA patients received antianginal drugs more frequently during follow-up than did CABG patients (at 2 years 61% vs 34%).

Conclusion

With a mean follow-up of 2.5 years, the risk for death or nonfatal myocardial infarction was not significantly different between patients with 1 to 3 diseased coronary arteries assigned to percutaneous transluminal coronary angioplasty or coronary artery bypass surgery.

Sources of funding: British Heart Foundation; British Cardiac Society; Department of Health; Advanced Cardiovascular Systems, Inc.; Medtronic Ltd.; Schneider.

For article reprint: Professor J.R. Hampton, Department of Medicine, D Floor, South Block, University Hospital, Nottingham NG7 2UH, United Kingdom. FAX 44-115-970-9384.


Commentary

This interim report by the RITA trial participants, halfway through their 5-year follow-up, represents the first publication from the 5 eagerly awaited randomized trials comparing angioplasty with bypass graft surgery treatment for angina pectoris. The other trials are the Bypass Angioplasty Revascularization Investigation (BARI), the Coronary Artery Bypass Revascularization Investigation (CABRI), the Emory Angioplasty vs. Surgery Trial (EAST), and the German Angioplasty Bypass Investigation (GABI). The importance of these new trials is highlighted by the fact that each year approximately 800 000 patients in North America have coronary revascularization, but only 2356 patients have previously been enrolled in comparative randomized trials (3 trials of medicine vs surgery and 1 trial of medicine vs angioplasty).

This study provides no clinical surprises. Angioplasty was easier to schedule and was associated with shorter hospital stays, shorter convalescent periods, increased repeat diagnostic and therapeutic interventions (probably because of restenosis), more recurrent angina, and an increased need for antianginal medications. Surgery, the more invasive procedure, provided more complete and sustained revascularization but required longer recovery and was more expensive. Importantly, there were no differences in mortality, MI, left ventricular ejection fraction, exercise time, or employment status.

This excellent trial has some limitations: The sample size is relatively small; fewer than 5% of screened patients were enrolled; 45% had single-vessel disease (which is usually best treated initially with angioplasty); and the follow-up is too short to factor in the complications of vein graft disease that usually develops after 5 years. Nevertheless, when the final results of these 5 trials and their nonrandomized registries are reported, we should have an excellent knowledge base for choosing the appropriate revascularization strategy for a given clinical situation. After all, the 2 revascularization techniques are more often complementary than are competitive interventions for a chronically progressive, complex disease state.

Eric Bates, MD
University of MichiganAnn Arbor, Michigan, USA


Editorial Comment

Since publication of this trial several additional randomized controlled trials have compared PTCA with CABG in the treatment of multivessel and high-risk single vessel coronary artery disease (1-7). In general, all of these studies had similar results and failed to show clear superiority of one procedure over the other in major endpoints—death and myocardial infarction, with the exception of patients with diabetes and multivessel coronary artery disease. The findings in patients with diabetes were derived from retrospective subgroup analyses and the optimal revascularization method for patients with diabetes and multivessel coronary artery disease is currently being evaluated in ongoing clinical trials. Patients treated with PTCA subsequently had more frequent angina and repeat revascularization procedures, while CABG was associated with longer hospital stays after the procedure but generally offered more complete revascularization.

New trials will evaluate the potential effect of new developments both in PTCA and CABG, such as the use of coronary stents and minimally invasive surgery, as well as the effect of aggressive cholesterol lowering in patients after having had a revascularization procedure.


References

1. King SB 3rd, Lembo NJ, Weintraub WS, et al. A randomized trial comparing coronary angioplasty with coronary bypass surgery. Emory Angioplasty versus Surgery Trial. N Engl J Med. 1994;331:1044-50.

2. Hamm CW, Reimers J, Ischinger T, et al.A randomized study of coronary angioplasty compared with bypass surgery in patients with symptomatic multivessel coronary disease. German Angioplasty Bypass Surgery Investigation. N Engl J Med. 1994;331:1037-43.

3. Rodriguez A, Boullon F, Perez-Balino N, et al.Argentine randomized trial of percutaneous transluminal coronary angioplasty versus coronary artery bypass surgery in multivessel disease (ERACI): in-hospital results and 1-year follow-up. ERACI Group. J Am Coll Cardiol. 1993;22:1060-7.

4. The Bypass Angloplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med. 1996;335:217-25.

5. First-year results of CABRI (Coronary Angioplasty versus Bypass Revascularisation Investigation). CABRI Trial Participants. Lancet. 1995;346:1179-84.

6. Hueb WA, Bellotti G, de Oliveira SA, et al. The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses. J Am Coll Cardiol. 1995;26:1600-5.

7. Goy JJ, Eeckhout E, Burnand B, et al. Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis. Lancet. 1994;343:1449-53.