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Stenting vs. Coronary Bypass Surgery for CAD

Analyses indicate that CABG is more cost-effective than stenting.

Controversy continues regarding the preferred treatment for many subgroups of patients who require revascularization for coronary artery disease. New analyses suggest that the value of stenting may be less than that of coronary artery bypass grafting in several settings.

A meta-analysis compared stenting with minimally invasive CABG of the left anterior descending artery. Stenting was associated with a higher rate of recurrent angina (odds ratio, 2.62), a higher incidence of major cerebral and coronary events (OR, 2.86), and greater need for repeat coronary revascularization (OR, 4.63). Mortality was similar with the two approaches. A cost-effectiveness analysis using the same data showed stenting to be more cost-effective in the first 2 years, but by 5 years CABG was more cost-effective.

Another cost-effectiveness analysis was based on a prospectively observed group of 1720 patients with CAD who were deemed clinically appropriate to receive CABG only, stenting, or both procedures. The patients actually underwent any of three approaches: CABG, stenting, or medical management. CABG was significantly more cost-effective than stenting in patients deemed appropriate for that procedure and in those deemed appropriate for both procedures. In none of the three groups was stenting most cost-effective.

Comment: These studies, using different approaches and different groups of patients, find that CABG is more likely to be cost-effective than stenting, at least as likely to reduce mortality, and less likely to lead to additional complications. These data did not include patients receiving drug-eluting stents. In an accompanying editorial, a cardiac surgeon calls for multidisciplinary teams that include noninterventional cardiologists and cardiac surgeons to be available to advise patients considering revascularization.

— Keith I. Marton, MD

Published in Journal Watch General Medicine April 5, 2007

Citation(s):

Aziz O et al. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ 2007 Mar 24; 334:617. (http://dx.doi.org/10.1136/bmj.39106.476215.BE)

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Rao C et al. Cost effectiveness analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ 2007 Mar 24; 334:621. (http://dx.doi.org/10.1136/bmj.39112.480023.BE)

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Griffin SC et al. Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: Prospective observational study. BMJ 2007 Mar 24; 334:624. (http://dx.doi.org/10.1136/bmj.39129.442164.55)

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Taggart DP. Coronary revascularization. BMJ 2007 Mar 24; 334:593. (http://dx.doi.org/10.1136/bmj.39154.552280.BE)

• Original article (Subscription may be required)
• Medline abstract (Free)