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


Therapeutics

PTCA and CABG had similar long-term mortality and myocardial infarction rates

ACP J Club. 1999 Mar-April;130:30. doi:10.7326/ACPJC-1999-130-2-030


Source Citation

Henderson RA, Pocock SJ, Sharp SJ, et al., for the Randomised Intervention Treatment of Angina (RITA-1) trial participants. Long-term results of RITA-1 trial: clinical and cost comparisons of coronary angioplasty and coronary-artery bypass grafting. Lancet. 1998 Oct 31;352:1419-25.


Abstract

Question

In patients with 1 to 3 diseased coronary arteries, are percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) equally effective at 6.5 years?

Design

Randomized controlled trial.

Setting

16 hospitals in the United Kingdom.

Patients

1011 patients {mean age 57 y, 81% men}* with angina and 1 to 3 diseased coronary arteries confirmed by angiography in whom equivalent revascularization was achievable by either PTCA or CABG. Exclusion criteria were need for immediate intervention, previous revascularization, left main-stem disease, valve disease, or potentially limited life span because of noncardiac disease. Follow-up was 99%.

Intervention

510 patients were allocated to PTCA and 501 to CABG. Interventions were to be done within 3 months. Other care was given at the discretion of the attending physician.

Main outcome measures

Death, nonfatal myocardial infarction, and combined death and nonfatal myocardial infarction. Resource costs were analyzed using 1997 U.K. prices discounted at 6%/y.

Main results

493 patients (98%) received PTCA and 490 (97%) received CABG. {At 2.5 years, the study groups did not differ for mortality or nonfatal myocardial in-farction.}* At median follow-up of 6.5 years, the groups did not differ for mortality (7.6% for the PTCA group vs 9.0% in the CABG group, P = 0.5), nonfatal myocardial infarction (10.8% for the PTCA group vs 7.4% for the CABG group, P = 0.08), combined death or myocardial infarction (17.1% for the PTCA group vs 16.0% the CABG group, P = 0.6), or mean health-services costs per patient (£8842 vs £9268, P = 0.3). More patients in the PTCA group had angina than did patients in the CABG group across all time periods.

Conclusions

Percutaneous transluminal coronary angioplasty had long-term rates of mortality and nonfatal myocardial infarction similar to those of coronary artery bypass grafting in patients with angina and 1 to 3 diseased coronary arteries deemed suitable for either intervention. Angina rates were higher after PTCA.

Sources of funding: U.K. Department of Health; British Heart Foundation; British Cardiac Society.

For correspondence: Dr. R.A. Henderson, Department of Cardiovascular Medicine, D Floor, South Block, University Hospital, Nottingham NG7 2UH, England, UK. FAX 44-115-970-9384.

*RITA Trial Participants. Lancet. 1993;341: 573-80.


Commentary

At least 8 randomized trials comparing PTCA and CABG have been reported this decade. They showed that PTCA was easier to schedule and was associated with shorter hospital stays and convalescent periods, increased repeated diagnostic and therapeutic interventions because of re-stenosis, more recurrent angina, and an increased need for antianginal medications. CABG provided more complete and sustained revascularization but required longer recovery times and was initially more expensive. No differences were shown in mortality, myocardial infarction, left ventricular ejection fraction, exercise time, employment status, or long-term costs.

These studies have several limitations. First, only 4% to 10% of patients eligible for revascularization were randomized. Second, the low-risk clinical and angiographic patient characteristics, including left ventricular ejection fraction > 50%, suggest that revascularization may not confer a survival advantage compared with medical therapy for most of these patients. Third, the combined results are underpowered to exclude a survival advantage for 1 treatment. Fourth, follow-up was too short to factor in the complications of vein graft disease that usually develop after 5 years. Finally, the studies were conceived > 10 years ago and do not reflect subsequent advances in experience and technology.

Endoluminal stenting and platelet GP-IIb/IIIa receptor inhibitors have improved PTCA outcome. It is not clear whether less invasive surgical techniques have improved outcomes after CABG. Several new trials are comparing outcomes and costs with contemporary medical therapy (aggressive risk factor control including the use of statins), PTCA (e.g., stents), and CABG (arterial grafts).

PTCA is the preferred treatment strategy for most low- and medium-risk candidates for revascularization. CABG has a documented survival benefit in high-risk patients (left main-stem disease, severe 3-vessel disease, and low ejection fraction). For most patients, the revascularization strategies are complementary rather than competitive interventions for a chronically progressive, complex disease state. The first therapeutic choice should be based on lesion characteristics and location, likelihood of PTCA success, completeness of revascularization, left ventricular function, comorbid conditions, and age.

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