Decisions of the Heart FAQ
Q1: How is coronary artery disease (CAD) treated?
A1: The three mainstays for treating CAD are medicine, coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) with the placement of one or more stents to reopen the coronary arteries.Q2: What treatment is best for me?
A2: According to the professional guidelines set forth by the American College of Cardiology (ACC) and American Heart Association (AHA), the decision to treat with CABG or PCI should be made objectively based on the following:- Medicine or PCI can treat patients with chronic stable (predictable) angina who have one-vessel or two-vessel CAD and no significant plaque in the left main or left anterior descending artery.
- CABG or PCI with stent placement may provide similar initial results in people with simple cases of “multi-vessel disease,” meaning three or more vessels, but not if the left main artery is affected by CAD.
- CABG provides best results for patients whose left main artery is blocked or those with multi-vessel disease that includes the left main artery.
- CABG surgery is recommended for patients who have diabetes, are of advanced age or have a condition where the function of the left ventricle of the heart is impaired.
Q3: What are the benefits and risks of PCI?
A3: PCI is a less invasive and less expensive procedure than CABG with significantly less pain and faster recovery time, which may be a more attractive option to patients. PCI has been shown to work well in patients with milder CAD (i.e., with single vessel disease and less complex cases of multi-vessel disease) and is typically associated with lower risk of complications during and immediately following the procedure.3,4,5However, with PCI there is an increased risk of the treated vessel reclosing and need for repeat PCIs; it results in a less complete reversal of ischemia and angina; and PCI patients who later require CABG may have poorer outcomes than patients who do not undergo previous PCI.6,7,8
Q4: What are the benefits and risks of CABG?
A4: Patients who have multi-vessel disease (i.e., three-vessel or left main coronary artery disease), or other risk factors such as diabetes, have better survival rates and chest pain resolution with CABG. There is usually complete reversal of ischemia (oxygen deprivation in the heart muscle), better angina relief, and reduced risk of repeat procedures. However, CABG is a more invasive procedure than PCI and has a longer recovery time, higher risk of complications during and immediately after the procedure, and a higher initial cost.3,4,5CABG can either be performed “on-pump” using a cardiopulmonary bypass machine or “off-pump,” referred to as off-pump coronary artery bypass (OPCAB) where the heart is kept beating during the procedure.9
- On-Pump Surgery: The majority of open heart cardiac surgery cases are performed using cardiopulmonary bypass (CPB), or a heart-lung machine that supports critical physiological functions for the patient’s body while the heart is being operated on.
- Off-Pump Surgery: OPCAB is a type of procedure that does not stop the heart and is done without putting the patient on a heart-lung machine; off-pump CABG may reduce complications associated with the heart-lung machine.
Q5: Who makes the decision about which treatment I should receive?
A5: To ensure you receive the best treatment for your condition, your case should be reviewed by a multidisciplinary “heart team” that consists of the following:- a medical cardiologist (a specialist who primarily treats heart disease with medications)
- an interventional cardiologist (a specialist who primarily treats CAD with stents in the cath lab)
- a cardiothoracic surgeon (a specialist who primarily treats CAD with surgery)
Q6: Why do I need to start having discussions with my heart team now?
A6: It is very important that patients take an active role in evaluating which treatment is best for their CAD as not all treatments have the same long-term outcome for all patients. In fact, studies have shown that not receiving the right treatment for CAD the first time may lead to additional procedures, impact a patient’s quality of life and may even decrease a patient’s survival over the long-term.You are entitled to ask questions and obtain second – and third – opinions during your CAD diagnosis process. Given the seriousness of CAD and the impact of alternative treatments on your quality and length of life, it is preferable, when possible, to take time to consult with the entire team of heart specialists before making any treatment decision.
Q7: Why would my doctor not follow the guidelines?
A7: There is ongoing debate as to the best treatment option for patients with complex CAD, and both CABG and PCI are a safe and effective approach for the right patient. Once a patient is diagnosed with CAD, making a treatment decision must often be made quickly.The patient’s desires are an important factor in the decision, and naturally less invasive procedures, like medicine or the placement of a stent, can be more attractive to patients. PCI has been shown to work well in a certain patient population – patients with milder CAD; however, for patients with complex CAD, CABG may be a better solution.10,11
1 Hannan EL, Racz MJ, Gold J, et al. Adherence of catheterization laboratory cardiologists to American College of Cardiology/American Heart Association guidelines for percutaneous coronary interventions and coronary artery bypass graft surgery. Circulation. 2010;121:267-275.
2 Anderson HV, Shaw RE, Brindis RG, et al. Relationship between procedure indications and outcomes of percutaneous coronary interventions by American College of Cardiology/American Heart Association Task Force Guidelines. Circulation. 2005;112:2786-2791.
3 Smith SC, Feldman TE, Hirshfeld JW, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2006;113:156–175.
4 Rihal CS, Raco DL, Gersh BJ, et al. Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable angina: review of the evidence and methodological considerations. Circulation. 2003;108:2439.
5 http://www.dukehealth.org/health_library/health_articles/multi_vessel_heart_disease
6 Mack M. Does percutaneous coronary intervention compromise the outcome of subsequent coronary artery bypass grafting? JACC: Cardiovascular Interventions. 2009;Vol. 2.
7 Kalayciolu S, Sinci V, Oktar L. Coronary artery bypass grafting (CABG) after successful percutaneous transluminal coronary angioplasty (PTCA): is PTCA a risk for CABG? Int Surg. 1998;83:190-3.
8 Chocron S, Baillot R, Rouleau JL, et al. IMAGINE Investigators Impact of previous percutaneous transluminal coronary angioplasty and/or stenting revascularization on outcomes after surgical revascularization: insights from the IMAGINE study. Eur Heart J. 2008;29:673-679.
9 Puskas JD, Williams WH, Duke PG, et al. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125(4):797-808.
10 Smith SC, Dove JT, Jacobs AK, et al. ACC/AHA guidelines for percutaneous coronary intervention: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2001;37:2215–38.
11 Hannan EL, Wu C, Walford G, et al. Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease. N Engl J Med. 2008;358:331-41.
