Current and Future Options in the Prevention and Treatment of Coronary Artery Disease with Special Reference to Surgical Aspect: Part II

Percutaneous coronary artery intervention (PCI) and coronary artery bypass grafting (CABG) are two means of revascularization of the ischemic heart. In patients with multivessel disease, it is apparent from long-term studies that CABG is associated with better survival and lower rates of major cardiovascular events and repeat revascularization are compared with PCI and drug-eluting stents. However, controversy remains in the use of PCI or CABG in diabetic patients with left main disease (LMD). This thematic issue discusses in detail the use of PCI and CABG revascularization of the ischemic heart due to coronary artery disease (CAD). This issue also discusses the current status of primary, secondary, and tertiary prevention of CAD.

The paper titled “Left main coronary artery disease in diabetes: PCI or CABG?” by Disney et al, describes in detail the choice of use of CABG and PCI in revascularization of LMD in patients with diabetes. They concluded that the patients with LMD and diabetes achieve similar benefits from PCI and CABG provided fewer than three vessels are affected, SYNTAX score is less than 33, and absence of distal bifurcation disease. Use of PCI may be appropriate for patients with less extensive CAD, or in patients with limited life expectancy or high surgical risk. The use of PCI in surgically high-risk patients may increase with the adoption of hybrid coronary revascularization and use of mechanical circulatory support.

Glen et al have provided an excellent review on the topic of “Percutaneous coronary intervention with stenting versus coronary artery bypass grafting in stable coronary artery disease.” This paper provides a summary of the existing data derived from randomized control trials and meta-analysis comparing CABG to PCI for patients with stable multiple vessel CAD. The above authors concluded that CABG was superior to PCI in all-cause mortality and need for repeat revascularization in patients with multivessel disease and stable CAD with or without diabetes mellitus. The rate of cerebrovascular events is lower with PCI compared with CABG. CABG provided significant advantages over PCI even with drug-eluting stents. The ideal end point for comparison of PCI with CABG still remains to be determined.

Lambert and Manetta in the paper titled “CABG Vs PCI in the treatment of unprotected left main disease in diabetes: a literature review” have discussed in detail the various randomized clinical trials (BARI, CARDIA, SYNTAX, FREEDOM, PRECOMBAT, EXCEL, and NOBLE) comparing the PCI with CABG in diabetic patients with CAD. They concluded that the clinical approach to left main CAD in diabetic patients remains debatable.

Anand et al, in the paper titled “Does age affect the short- and long-term outcomes of coronary bypass grafting” have described in detail the short- and long-term outcomes of CABG in four age groups of patients (below 40 years of age, between ages of 40 and 60 years, between ages of 60 and 80 years, and above 80 years of age). The measured outcomes included all-cause death, myocardial infarction, cerebrovascular events, and repeat vascularization They concluded that CABG at a younger age results in high survival with low adverse events, and arterial graft is superior to vein graft until the age of 80 years and advanced age should not deter the use of CABG. Patients below 40 years of age fare best with total arterial revascularization. Patients between 40 and 60 years of age do well with multiarterial graft (MAGs), while either MAGs or single arterial graft benefit patients above 60 years of age, and the benefits are best in younger and diabetic patients. Operative intervention begins to show significant mortality above the age of 80 years, but this risk is countered by maintenance or improvement in quality of life.

Winker et al have provided an extensive review on the topic titled “Three techniques that will guide revascularization of chronic coronary syndrome patients in 21^st century: A review.” Although medical therapy and revascularization are both complimentary and competing therapies for chronic coronary syndrome (CCS), these authors have focused on revascularization. Technical advances in diagnosis, patient selection procedural guidance, stent technology, and procedural technique take part in revascularization. The three technologies including cardiac computed tomography (CT), intracoronary imaging, and lesion specific physiological guidance have proven to be best diagnostic tools. CT-FER is better than conventional cardiac CT. Optical coherence tomography may be proved to be superior to intravascular ultrasound. iFR has begun to supplant FER because of its simplicity, efficiency, and free from side effects. Optimal medical therapy is standard care for patients with CCS. Revascularization is considered for patients with angina that persists despite maximal antianginal regime. CCS patients who may benefit from revascularization include those often excluded from clinical trials and patients with left ventricular dysfunction, heart failure, LMD, and severe multivessel disease.

Prasad K. in the paper titled “Current status of primary, secondary, and tertiary prevention of coronary artery disease” defines the terminology of primary, secondary, and tertiary prevention of CAD and discusses the mechanism of risk factor-induced atherosclerosis that leads to CAD. He describes the modifiable risk factors for CAD, and CAD risk score and its use in the selection of individuals for primary prevention of CAD. The guidelines of the three types of prevention of CAD have been described in detail. There seems to be some overlap between the guidelines of secondary and tertiary prevention of CAD. He has included AGE (advanced glycation end products)-RAGE (receptor for AGE)-stress, a new risk factor for CAD, and has discussed in short the treatment of AGE-RAGE stress for the prevention of primary, secondary, and tertiary prevention of CAD. Primary, secondary, and tertiary prevention of CAD would prevent, regress, and slow down the progression of CAD, improve the quality of life of patients, and reduce health-care cost.

We are very appreciative to all the authors for their contribution of superior quality papers in this thematic issue. We thank the reviewers for their time, comments, and suggestions. We acknowledge the support of Denise M. Rossignol, Executive Director of International College of Angiology, and Managing Editor of International Journal of Angiology, in completing this task.

Publication History

Article published online:
10 November 2021