Health knowledge made personal
Join this community!
› Share page:
Go
Search posts:

Patient Choice and Coronary Artery Stenting Versus CABG

Posted Mar 21 2011 12:00am

I strongly favor the idea of patient choice regarding all types of therapy and surgery. After all, participation, meaning patient participation, is one of the "Four P's" of modern healthcare that was discussed in a previous note (see: The Future of Healthcare and the Four P's: Preventive, Predictive, Personalized, Participatory ). Patient choice was raised in a recent article about stenting versus surgery for obstructive coronary artery disease (see: Choice of Surgery or Stenting Can Be Left to Patient ):

For patients with three-vessel or left main coronary artery disease undergoing multivessel revascularization, CABG and percutaneous coronary intervention (PCI) with drug-eluting stents both had advantages for the relief of angina....Among these patients, compared with PCI, CABG resulted in slightly but significantly better scores on a measure of angina frequency at both six and 12 months after the procedure....But on nearly all other secondary measures of cardiac-specific or general health-related quality of life, PCI topped CABG by one month after recovery, although the differences largely disappeared by six months....[One of the authors] said there was no clear winner in the study, adding that the findings should help patients decide which procedure is best for them. "If what's most important to a patient is getting the absolute best relief of their chest pain, then a bypass operation would seem to be the way to go because it did have better outcomes for those very specific endpoints," he said in an interview. "On the other hand, if a patient really values their quality of life in the short term ... and doesn't mind the possibility that they will have a little worse angina in the long run, then a PCI might be favored,"....[He] said that, in his experience, patients tend to prefer the quick recovery offered by PCI, an observation that seems to be supported by national data showing that about four times as many stenting procedures as bypass surgeries are performed each year.

What I found most interesting about this article that compares coronary bypass graft (CABG) with drug-eluting stents (PCI) is that "there was no clear winner" when the two techniques were compared in a scientific study. Hence, it was deemed acceptable, in such a case, to allow the patient to decide the type of therapy. I think this article moves in the right direction. However, the implication is that patient choice is acceptable because the two alternative therapies have been judged by experts to be roughly equal. In my opinion, patients should be allowed to choose their therapy even if the, say, two therapeutic alternatives do not seem equal in the mind of the presenting physician.

One more point, I think that the choice of competing therapies, when such a choice exists, should be discussed with a patient by a professional who does not have a financial or professional stake in the outcome. I am not exactly sure how this can be accomplished given that the alternatives are most commonly presented by a physician who may not be totally objective. Perhaps the answer is a web site or patient education app that lists the pro's and con's of competing therapies for various common diseases. Even in the case presented above that seems very straightforward, one obvious option is not discussed -- no treatment at all. I suspect most physicians would not raise this at all given that stenting is considered to be relatively benign. However, even stenting is associated with a finite complication rate which could be magnified in a very old or frail patient (see: Using a Frailty Index to Determine Whether to Operate on an Elderly Patient ).

Please NoteAfter viewing this article, you will be asked to log in or create an account in order to continue reading additional articles and access everything MedPage Today has
to offer. It’s free and your information will not be shared.
Choice of Surgery or Stenting Can Be Left to Patient
By Todd Neale, Staff Writer, MedPage Today
Published: March 17, 2011
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner     Earn CME/CE credit
for reading medical news
For patients with three-vessel or left main coronary artery disease undergoing multivessel revascularization, CABG and percutaneous coronary intervention (PCI) with drug-eluting stents both had advantages for the relief of angina, a substudy of the SYNTAX trial showed.

Among these patients, compared with PCI, CABG resulted in slightly but significantly better scores on a measure of angina frequency at both six and 12 months after the procedure (P<0.05), according to David Cohen, MD, of Saint Luke's Mid America Heart Institute in Kansas City, Mo., and colleagues.

But on nearly all other secondary measures of cardiac-specific or general health-related quality of life, PCI topped CABG by one month after recovery, although the differences largely disappeared by six months, the researchers reported in the March 17 issue of the New England Journal of Medicine.
Action Points 

    * Explain that in patients with three-vessel or left main coronary artery disease undergoing multivessel revascularization, CABG resulted in slightly but significantly better scores of angina frequency at both six and 12 months after the procedure, compared with percutaneous coronary intervention (PCI) with drug-eluting stents.


    * Point out that on nearly all other secondary measures of cardiac-specific or general health-related quality of life, PCI topped CABG by one month after recovery, although the differences largely disappeared by six months.

Cohen said there was no clear winner in the study, adding that the findings should help patients decide which procedure is best for them.

"If what's most important to a patient is getting the absolute best relief of their chest pain, then a bypass operation would seem to be the way to go because it did have better outcomes for those very specific endpoints," he said in an interview.

"On the other hand, if a patient really values their quality of life in the short term ... and doesn't mind the possibility that they will have a little worse angina in the long run, then a PCI might be favored," he said.

Cohen said that, in his experience, patients tend to prefer the quick recovery offered by PCI, an observation that seems to be supported by national data showing that about four times as many stenting procedures as bypass surgeries are performed each year.

The main results of the SYNTAX trial showed that CABG resulted in a lower rate of a composite of death, MI, stroke, or repeat revascularization than PCI with paclitaxel-eluting (Taxus Express) stents in 1,800 patients with three-vessel or left main coronary artery disease who were suitable for either procedure.

The benefit was primarily driven by a reduction in the need for repeat procedures.

Because there was no difference in a composite of irreversible outcomes -- death, MI, and stroke -- other considerations, including quality of life, become part of the decision about which procedure to choose, the researchers wrote in their paper.

In this substudy, Cohen and his colleagues looked at cardiac-specific quality of life measured using the Seattle Angina Questionnaire (SAQ) and general health-related quality of life measured using the Medical Outcomes Study 36-item Short-Form Health Survey and the European Quality of Life-5 Dimensions instrument.

The primary endpoint was the score on the SAQ angina-frequency subscale; higher scores indicate better health status.

Overall, quality of life scores improved for patients in both groups at both six and 12 months.

Although there was a statistically significant advantage for CABG on the primary endpoint at both six and 12 months, the average between-group difference -- 1.7 points -- was small.

The proportion of patients who had an increase of at least 20 points from baseline -- which was considered substantial improvement -- varied from 52.4% to 58.3% at each time point, with no between-group differences.

At 12 months, a greater percentage of patients in the CABG group were free from angina (76.3% versus 71.6%, P=0.05).

In general, scores on nearly all of the other subscales of the three quality-of-life measures were better in the PCI group by one month, with between-group differences mostly vanishing by six months.

Cohen and his colleagues noted in their paper that previous studies have shown somewhat larger advantages in angina relief and quality of life for CABG compared with PCI with either balloon angioplasty or bare-metal stents, and that the current findings appear to indicate that the use of drug-eluting stents has narrowed the gap.

They acknowledged that the findings might not be generalizable to all patients with three-vessel or left main coronary artery disease.

Additional limitations include the lack of long-term outcomes beyond one year, some missing data, and the differential use of calcium channel blockers and long-acting nitrates in the two groups.
Post a comment
Write a comment: