How should stable coronary artery disease be managed in the modern era?

CABG offers a cost-effective and better long-term clinical outcome for many patients oronary artery disease is still the single largest cause of premature death in Australia, according to the Australian Institute of Health and Welfare. 1 Also documented is the dramatic decline in age-related mortality from heart disease, which is largely attributed to reductions in smoking and better intervention for hyperlipidaemia and elevated blood pressure. 2 As many as 85% of elective percutaneous coronary intervention (PCI) procedures are done in patients with stable coronary artery disease. 3 However, the only data showing prognostic benefit of intervention in reducing death and infarction in such patients come from subgroup analyses in old surgical trials, 4-6 which showed benefits for patients with left main, triple vessel or proximal left anterior descending stenoses, especially if there was additional left ventricular damage. These benefits lasted up to 11 years, but the surgery was compared with medical therapy that did not include aspirin, β-blockers or lipid-lowering therapy for most patients. The surgical group did not receive arterial conduits. Subsequently, 11 randomised trials comparing PCI with coronary artery bypass graft (CABG) surgery for patients with multives-sel coronary artery disease showed that the frequency of death and myocardial infarction was similar in both arms. 7 These results cannot be used to claim an outcome benefit for PCI, as the trials entered only about 5% of screened patients, and the patients were not equivalent in the severity of their coronary artery disease to those in the original CABG trials. Further, analysis of the comparative trials shows that the highest-risk group (those with diabetes) showed benefit with CABG over PCI. 8 Outcomes after CABG now show that, despite this surgery being performed in increasingly sick and complex patients, the overall mortality is less than 2%. 9 Average length of hospital stay is now 3–5 days and return to work is usual in less than 2 months. Improved techniques have reduced the problem of cognitive impairment, and comparative studies have shown no difference with PCI in this respect. 10 Long-term outcomes of CABG have improved due to the increased use of arterial conduits. Repeat CABGs now make up only 3%–4% of total CABG surgery, although this low figure may reflect a preference for PCI in repeat procedures. PCI has flourished since its introduction 30 years ago, with its offer to patients of a sound and timely intervention for coronary artery disease …