How to choose between CABG and PCI when treating coronary artery disease
When treating coronary artery disease (CAD), choosing between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) remains a critical question. Despite patients often leaning toward PCI to avoid surgery, clinical evidence still supports the use of CABG due to its increased durability over time.
"Patient selection really is the key," John D. Puskas, MD, MSc, PhD, professor of surgery and chief of cardiothoracic surgery at Emory University Hospital Midtown, told Cardiovascular Business at the American Heart Association (AHA) 2024 Scientific Sessions. "We have three modalities to treat patients with coronary art disease, the No. 1 killer of human beings. We have medicines, we have PCI, and we have coronary bypass surgery. We want to pick which is best and we want to find the right patient to receive PCI with medical therapy or CABG with medical therapy. And that's been a contentious issue within cardiovascular care. There's a little bit of turf war, but at the end of the day, we're a heart team. Our job is to serve the patient and to figure out which is best for the patient."
While both CABG and PCI are used to restore blood flow in blocked coronary arteries, Puskas emphasized that each option has distinct advantages depending on the patient’s clinical profile and life expectancy.
CABG, for instance, is best suited for younger, healthier patients, especially those with complex, multivessel disease and diabetes.
“We perform bypass surgery to eliminate symptoms of angina to prevent future myocardial infarction, thereby improving quality of life and prolonging length of life. Those are the reasons we do coronary bypass surgery," Puskas said.
By contrast, PCI is typically favored for older patients with a shorter life expectancy, patients with several comorbidities and frail patients with lower-complexity disease who may not tolerate the invasiveness of surgery.
"PCI is a less invasive procedure. It can treat a focal lesion, manage a symptom or mitigate it against an acute myocardial infarction and avoid the big invasion of a surgical procedure," he explained.
Puskas also pointed out trends he believes needs correcting to better serve patients and not the interests of a specific specialty. “We do way too much PCI in young, diabetic patients with complex disease. That's a mistake. At the same time, we do too much CABG in elderly, frail patients who just need symptom relief—not a major surgery,” he said.
Scoring systems to help decide between CABG and PCI
To aid in the decision-making process, clinicians often use two key scoring systems: the SYNTAX score and the Society of Thoracic Surgeons (STS) risk score. The SYNTAX score measures the complexity of coronary anatomy and is especially relevant for PCI outcomes—higher scores suggest poorer outcomes with PCI. Meanwhile, the STS score evaluates surgical risk based on comorbidities and helps predict outcomes for CABG patients.
Just as the SYNTAX score does not really impact outcome predictions for CABG, the same is true of the STS scores in PCI. But there is is a crossover point between these two scores that can help with clinical decision making.
“Patients with a high SYNTAX score and a low STS score are better suited for CABG. Those with a low SYNTAX score and a high STS score are best treated with PCI,” Puskas explained.
At the heart of the decision is a patient-centered approach, he said. Turf wars between cardiologists and surgeons should not matter if the physicians work together to determine what iS best for the patients. For this reason, he feels the best approach to CAD care is when both surgeons and interventionists work together on heart teams for shared decision making.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]