WASHINGTON — With recent data from the FREEDOM and SYNTAX trials showing improved rates of mortality and MI in patients with advanced CAD treated with CABG compared with PCI, many interventionalists are left questioning the role of stenting in the future management of this patient population.
However, the decision of whether to perform stenting or surgery in the setting of advanced CAD requires unbiased judgment and necessitates factoring in more variables than just mortality and MI, according to David Holmes, MD, of the Mayo Clinic.
“All of the data would suggest that PCI still has an incredibly important role to play [with advanced CAD management] in select patients,” he said during a presentation.
Holmes highlighted the findings of the FREEDOM trial that were presented at the American Heart Association Scientific Sessions last year. Although showing significantly higher rates of mortality and MI in patients with diabetes and multivessel CAD treated with PCI, the rate of stroke in FREEDOM was significantly higher in the CABG arm, a distinction that has not received much attention, Holmes said.
“For most patients, if you were to tell them that they can have a stroke, they would say that’s a pretty big deal,” he said.
Holmes also looked at the 5-year results of the BARI trial, which were published more than a decade before FREEDOM. In the trial, patients with diabetes were randomly assigned to conventional percutaneous transluminal coronary angioplasty (PTCA) or CABG. Among patients who were randomly assigned, those in the PTCA arm had significantly greater 5-year all-cause mortality; however, those who were not randomly assigned were placed in a registry, and similar 5-year all-cause mortality was reported between groups (PTCA, 14.4% vs. CABG, 14.9%; P=.86).
“What that meant was that you as a physician could look at a patient and lesion and say this seems reasonable to treat with PTCA and this [patient/lesion] seems reasonable to treat with CABG,” Holmes said.
Additionally, Holmes discussed the elusiveness of obtaining an unbiased opinion between surgical and interventional specialists, but said full disclosure must be an essential part of the equation.
“As you find and identify strategies, we need to make sure we give patients full disclosure information,” he said, adding that some patients consider stroke the very worst event, and if they are faced with an option that gives them twice the chance of a stroke rather than the need for a repeat revascularization, it might noticeably influence their decision making.
In the end, Holmes said the priority for physicians is to deliver care that is appropriate and customized to the patient’s needs and values. “We need to give them the full dataset in as unbiased fashion as we can, including all risks and benefits, in terms they can understand.
“So, at the end of the day, PCI is going to remain an incredibly valued and valuable player in the field of taking care of patients with more advanced CAD. It will not go away,” he concluded. – by Brian Ellis
For more information:
Holmes D. Complex Coronary Interventions II. After FREEDOM and SYNTAX: Can PCI be an alternative to surgery in patients with multivessel disease? Presented at: Cardiovascular Research Technologies; Feb. 23-26, 2013; Washington, D.C.