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Management of Chronic Stable Angina: Medical Therapy, Percutaneous Transluminal Coronary Angioplasty, and Coronary Artery Bypass Graft Surgery: Lessons from the Randomized Trials

Allen J. Solomon, MD; and Bernard J. Gersh, MB, ChB, DPhil
[+] Article and Author Information

From Georgetown University Medical Center, Washington, D.C. Acknowledgment: The authors thank Wendy Steele for skillful preparation of the manuscript. Requests for Reprints: Allen J. Solomon, MD, Georgetown University Medical Center, Division of Cardiology, Room M4222, 3800 Reservoir Road, NW, Washington, DC 20007. Current Author Addresses: Dr. Solomon: Georgetown University Medical Center, Division of Cardiology, Room M4222, 3800 Reservoir Road, NW, Washington, DC 20007.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1998;128(3):216-223. doi:10.7326/0003-4819-128-3-199802010-00008
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Purpose: To review the available data on the treatment of chronic stable angina and formulate a rational approach to the use of pharmacologic therapy, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft surgery (CABG).

Data Sources: A MEDLINE search of the English-language literature published between 1976 and 1996 and the bibliographies of relevant articles.

Study Selection: Primary research articles, meta-analyses, and meeting abstracts related to the management of chronic stable angina with an emphasis on comparisons of medical therapy, PTCA, and CABG.

Data Extraction: Three trials comparing medical therapy with PTCA, seven trials comparing medical therapy with CABG, and nine trials comparing PTCA with CABG.

Data Synthesis: Low-risk patients with single-vessel coronary artery disease and normal left ventricular function had greater alleviation of symptoms with PTCA than with medical treatment; mortality rates and rates of myocardial infarction were unchanged. In high-risk patients (risk was defined by severity of ischemia, number of diseased vessels, and presence of left ventricular dysfunction), improvement of survival was greater with CABG than with medical therapy. In moderate-risk patients with multivessel coronary artery disease (most had two-vessel disease and normal left ventricular function), PTCA and CABG produced equivalent mortality rates and rates of myocardial infarction.

Conclusions: In low-risk patients, a strategy of initial medical therapy is reasonable. In moderate-risk patients, PTCA and CABG produce similar mortality rates and rates of myocardial infarction but PTCA-treated patients require more revascularization procedures. In high-risk patients, CABG is usually preferred.

Figures

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Figure 1.
Percentage of patients who were free of angina after randomization in the ACME (Angioplasty Compared to Medicine) study.[7]

White bars indicate medical therapy; striped bars indicate percutaneous transluminal coronary angioplasty. Adapted from Parisi and colleagues with permission.

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Figure 2.
Cumulative mortality data from the meta-analysis of coronary artery bypass graft surgery (CABG) (1324 patients) compared with medical therapy (1325 patients).[4]

Solid line indicates medical therapy; dashed line indicates CABG. Adapted from Yusuf and colleagues with permission.

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Figure 3.
Overall combined risk for death and nonfatal myocardial infarction in five randomized trials comparing percutaneous transluminal coronary angioplasty (PTCA) with coronary artery bypass graft (CABG) surgery.[29]

CABRI = Coronary Angioplasty Bypass Revascularization Investigation; EAST = Emory Angioplasty versus Surgery Trial; ERACI = Estudio Randomizado Argentino de Angioplastia vs Cirugia; GABI = German Angioplasty Bypass Surgery Investigation; OR = odds ratio; RITA = Randomised Intervention Treatment of Angina. Reproduced from Sim and coworkers with permission.

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Figure 4.
Risk for repeated percutaneous transluminal coronary angioplasty (PTCA) (white bars), coronary artery bypass graft (CABG) surgery (striped bars), or both (black bars) after randomization in six trials comparing PTCA with CABG.

BARI = Bypass Angioplasty Revascularization Investigation; CABRI = Coronary Angioplasty Bypass Revascularization Investigation; EAST = Emory Angioplasty versus Surgery Trial; ERACI = Estudio Randomizado Argentino de Angioplastia vs Cirugia; GABI = German Angioplasty Bypass Surgery Investigation; RITA = Randomised Intervention Treatment of Angina.

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Figure 5.
Cumulative costs during follow-up of patients randomly assigned to percutaneous transluminal coronary angioplasty (solid line) or coronary artery bypass graft surgery (dashed line) in the Bypass Angioplasty Revascularization Investigation.[30]

Adapted from Hlatky and colleagues with permission.

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Figure 6.
Five-year survival rates comparing patients being treated for diabetes mellitus with all other patients in the Bypass Angioplasty Revascularization Investigation.[26]

Diabetic patients assigned to coronary artery bypass surgery (CABG) are indicated by the heavy solid line; all other patients assigned to CABG are indicated by the light solid line; diabetic patients assigned to percutaneous transluminal coronary angioplasty (PTCA) are indicated by the heavy dashed line; and all other patients assigned to PTCA are indicated by the light dashed line. Adapted from with permission.

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