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The Beta Blocker and Clonidine Protocol

Lesson 3
Risk Stratification

17. Risk & Benefit of CABG vs. other Therapies Over Time

Risk of CABG vs PCI vs Medical Therapy at Two Years

Under et. al. J Thorac Cardiovasc Surg. 2003 Apr;125(4):809-20
1205 Patients randomized CABG vs PCI

Risk of CABG vs PCI vs Medical Therapy @ 2 yrs

At two years, there is no advantage of CABG over PCI.

At five years, there is a difference between medical (83%), PCI (92%), and CABG (91%) survival. Dzavik Am Heart J. 2001 Jul;142(1):119-26 But this is at five years. Very few people will choose to risk dying today to avoid dying five years from now. This study should integrate total days living, not just survival at 5 years because it will take more than five years to have the total days surviving to be improved if the first survival advantage is at five years. Moreover, the patient is coming for elective non-cardiac surgery. Should you be offering a possibility of better survival five years from now when the cost is a 3.2% 30-day mortality and 3 - 6% chance of stroke today?

Benefit of CABG vs PTCA at 5 years

Dzavik Am Heart J. 2001 Jul;142(1):119-26

Cumulative 5-year survival 11,661 patients with CAD:

bullet CABG 91.4%
bullet PCI 91.9%
bullet Medical Therapy 82.9% (P <.001).

Hazard Ratios:

bullet CABG: medical 0.53 (95% confidence interval [CI] 0.46-0.71)
bullet PCI: medical 0.65 (95% CI 0.56-0.74)
bullet CABG: PCI 0.81 (95% CI 0.68-0.96)
bullet Severe Left Main shows advantage of CABG over CAD: 0.30 (95% CI 0.17-0.54).

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Content by Art Wallace MD PhD
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