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BMJ 2011; 342 (Published 2 June 2011)
Editorial


Medical treatment, PCI, or CABG for coronary artery disease?

Andre Lamy, cardiac surgeon,
Madhu Natarajan, interventional cardiologist,
Salim Yusuf, non-interventional cardiologist




The three approaches should complement one another, not compete

Medical treatments of coronary artery disease have improved in the past decade because of the availability of statins, effective blood pressure lowering drugs (in particular angiotensin converting enzyme inhibitors), calcium blockers, and antiplatelet agents. 1 In addition, improvements in percutaneous coronary interventions (PCI) have revolutionised the management of high risk people with acute myocardial infarction (primary PCI and rescue PCI) and non-ST elevation myocardial infarction and unstable angina. The use of stents, together with antiplatelet and antithrombotic treatments, has reduced procedural complications and made PCI safer. 2 Drug eluting stents have reduced restenosis after PCI, although they increase late stent thrombosis, for which long term dual antiplatelet treatment is required. 3

Improvements in coronary artery bypass (CABG) surgery have been slow because only a few randomised controlled trials have been performed. Surgeons still debate the benefits of off-pump CABG (beating heart surgery) versus on-pump surgery, 4 and whether double internal mammary artery grafts are superior to single internal mammary grafting. Both questions are currently being evaluated in large randomised trials. 5 Given that CABG surgery is increasingly performed in older people who are at high risk of cardiac, neurological, and renal complications, it is notable that CABG surgery results are improving worldwide.

In October 2010, a joint task force of the European Society of …

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