Detailed prediction models that project long-term patient mortality following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) surgery can be useful for the heart team when determining the best treatment strategy for individual patients, according to a study in the February 2014 issue of The Annals of Thoracic Surgery.
"One problem with cardiovascular care today is that PCI and CABG are viewed as competitive procedures," said Joseph F. Sabik III, MD. "Our study attempts to show that these procedures should instead be seen as complementary. Depending on patient comorbidities and extent of coronary artery disease, some patients have better survival after CABG, while other patients experience better outcomes following PCI."
Dr. Sabik and researchers from the Cleveland Clinic in Ohio used patient data from two registries to develop survival models for CABG and PCI. CABG is a surgical procedure in which arteries or veins from elsewhere in the body are grafted to the coronary arteries, bypassing the narrowed or blocked area to improve blood supply. PCI involves non-surgical procedures, such as balloon angioplasty or stent placement, to open narrowed coronary arteries.
From 1995 to 2007, 13,114 patients at the Cleveland Clinic underwent CABG surgery, 6,964 underwent PCI with bare-metal stents (BMS), and 3,104 underwent PCI with drug-eluting stents (DES). Survival models were developed independently for each therapy, and all factors appearing in any of the three models were then programmed into a decision-support tool, which enabled researchers to examine long-term survival rates for each procedure.
Analysis showed that patients with more extensive coronary artery disease and those who had more comorbidities experienced better outcomes after undergoing CABG surgery, while patients who had acute myocardial infarction (heart attack) or had more limited coronary artery disease had better long-term outcomes after PCI.
"Our study suggests that patients should be more engaged in their own health care decisions," said Dr. Sabik. "When meeting with their surgeon or physician, patients should ask how the treatment strategy was determined -- Did they consult with a heart team, and did they consider both PCI and surgery?"
The heart team involves a team-based approach to cardiac care connecting the patient to many practitioners, including primary cardiologists, interventional cardiologists, cardiac surgeons, imaging specialists, and nurses, among others.
Importance of Comprehensive Approach to Patient Care In an invited commentary in the same issue of The Annals, A. Pieter Kappetein, MD, PhD and Ruben Osnabrugge, MD, from Erasmus MC in Rotterdam, The Netherlands, commented on the need for a risk-benefit analysis to be used in conjunction with a heart team approach for patient care. "Treatment models help physicians make recommendations, but a heart team approach to individualize treatment is needed to ensure that every patient receives the optimal therapy," said Dr. Kappetein.
"This study provides an example of how treatment models can be used to predict long-term outcomes after PCI and CABG in patients with aortic stenosis," said Dr. Kappetein. "Hopefully future models also will be able to predict outcomes in addition to just mortality."
- Sajjad Raza, Joseph F. Sabik, Stephen G. Ellis, Penny L. Houghtaling, Kerry C. Rodgers, Aleck Stockins, Bruce W. Lytle, Eugene H. Blackstone. Survival Prediction Models for Coronary Intervention: Strategic Decision Support. The Annals of Thoracic Surgery, 2014; 97 (2): 522 DOI: 10.1016/j.athoracsur.2013.06.099
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