BARI findings on PTCA and CABG are ongoing
Treatment differences narrow over the long term
Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) are typically recommended for patients with multivessel coronary artery disease (CAD) and ischemic symptoms. Patients undergoing revascularization by either treatment generally survive many years. Assessment of treatment efficacy, therefore, must consider short- and long-term improvements and cost issues.
The randomized Bypass Angioplasty Revascularization Investigation (BARI) trial is the largest study to date comparing the two coronary revascularization methods.1,2 The investigators followed 1,829 patients at 18 clinical centers for five years after they underwent either CABG or PTCA. All patients in the trial had multivessel CAD, had not been previously revascularized, and were suitable candidates for both CABG and PTCA. Participants had scheduled follow-up at four to 14 weeks after study entry, at six months, and annually through five years.
Whether they had CABG or PTCA, patients in the BARI trial achieved material reductions in angina accompanied by improvements in quality of life. Three percent of each group had unstable or severe angina five years after initial revascularization. Patients assigned to PTCA were more likely to have angina and exercise-induced ischemia and required a greater number of additional procedures, although the differences between the two groups narrowed over time up until this five-year look. The narrowing can be attributed, say investigators, to a return of symptoms among patients assigned to CABG and incremental surgical procedures among patients assigned to PTCA.
Use of anti-ischemic and lipid-lowering medication was higher in patients assigned to PTCA, and more bypass patients reported using diuretics through the follow-up period. CABG patients were more likely than PTCA patients to use digitalis early on, but the difference was no longer substantial by the fifth year. Significant is the fact that among patients who were angina-free at five years, 52% of patients who were assigned to PTCA required revascularization after the initial procedure while only 6% of CABG patients required revascularization.
Patients who underwent CABG were more likely to have procedure-related myocardial infarctions 8% to 10% as compared to 2% to 3% for angioplasty but most events were well tolerated.
Among those employed, a greater percentage of PTCA patients were able to return to work by the four- to 14-week follow-up 55% as compared to 36%. CABG patients also were more likely to report limitations on their jobs and social lives over that period. At the one-year follow-up, indicators for return to work, as well as smoking cessation, exercise, lowered cholesterol levels and general quality of life were similar for the two treatments.
The researchers write, "The longer recovery time needed following bypass surgery is reflected in the PTCA patients’ earlier return to work and the CABG patients’ more frequent reporting of limitations . . . at their early follow-up. Otherwise, standard quality of life outcomes and behavioral risk factors were similar for the two treatment groups."
References
1. King SB, Lembo NJ, Weintraub WS, et al. A randomized trial comparing coronary angioplasty with coronary bypass surgery. N Engl J Med 1994; 331:1,044-1,050.
2. Hamm CW, Reimers J, Ischinger T, et al. A randomized study of coronary angioplasty compared with bypass surgery in patients with symptomatic multivessel coronary disease. N Engl J Med 1994; 331:1,037-1 043.
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