abc

Arquivos Brasileiros de Cardiologia

Arq. Bras. Cardiol.

0066-782X 1678-4170

Sociedade Brasileira de Cardiologia - SBC

São Paulo, SP, Brazil

Vg8rJybBrnVj7tqz7Zx7Tvb

00021

S0066-782X2011001200021

S0066-782X(11)09700321

10.1590/S0066-782X2011001200021

Atualização Clínica

Angioplastia coronariana versus cirurgia de revascularização: revisão de estudos randomizados

Andrade

Pedro José Negreiros de

Medeiros

Marta Maria das Chagas

Andrade

Antonio Thomaz de

Lima

Antonio Augusto Guimarães

Ceará

Universidade Federal do Ceará Faculdade de Medicina Departamento de Medicina Clinica Brazil

Ceará

Universidade Federal do Ceará Hospital Universitário Walter Cantidio Serviço de Cardiologia Brazil

São Paulo

Instituto Dante Pazzanese de Cardiologia Brazil

09 2011

97 3 e60 e69 24 09 2010 23 08 2010 14 05 2010

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Realizamos uma revisão com agregação de resultados dos ensaios randomizados que compararam intervenção coronariana percutânea (ICP) com cirurgia de revascularização miocárdica (CRM). Os 25 ensaios selecionados envolveram 12.305 pacientes dos quais 11.103 pertenciam a estudos em multiarteriais e 1.212 pertenciam a estudos em lesão única de descendente anterior (DA). Nos estudos em multiarteriais a ICP mostrou uma tendência a menor mortalidade precoce (1,2% versus 2%) e menor incidência de acidente vascular cerebral (AVC): 0,7% versus 1,65%. Não houve diferença na mortalidade intermediária (3,8% versus 3,8%). Houve tendência à superioridade da CRM na mortalidade tardia (10,5% versus 9,6%). A diferença deveu-se exclusivamente aos estudos da era balão, tendendo a inverter-se na era stent (9,6% versus 9,9%). Nos estudos de lesão única de DA não houve diferença significativa em nenhum desfecho. A agregação de resultados de nove estudos que avaliaram a mortalidade tardia em diabéticos mostrou diferença favorável à cirurgia (21,3% versus 15,9%). Dois estudos que avaliaram lesão de tronco não mostraram diferença significativa na mortalidade em um ano (3,9% versus 4,7%). A incidência de nova revascularização foi consistentemente maior na ICP, apesar de progressiva melhora dos resultados na era stent.

Angioplastia transluminal percutânea coronariana ponte de artéria coronária revascularização miocárdica metanálise estudo comparativo revisão

21 10 2011

ATUALIZAÇÃO CLÍNICA

Angioplastia coronariana versus cirurgia de revascularização: revisão de estudos randomizados

Pedro José Negreiros de Andrade^I; Marta Maria das Chagas Medeiros^II; Antonio Thomaz de Andrade^III; Antonio Augusto Guimarães Lima^I

^IServiço de Cardiologia do Hospital Universitário Walter Cantidio da Universidade Federal do Ceará

^IIDepartamento de Medicina Clinica da Faculdade de Medicina da Universidade Federal do Ceará

^IIIFortaleza, CE; Instituto de Cardiologia Dante Pazzanese, São Paulo, SP - Brasil

Correspondência

Resumo

Palavras-chave: Angioplastia transluminal percutânea coronariana, ponte de artéria coronária, revascularização miocárdica, metanálise, estudo comparativo, revisão.

Introdução

Tanto a intervenção coronariana percutânea (angioplastia ou ICP) quanto a cirurgia de revascularização miocárdica (cirurgia ou CRM) são alternativas bem aceitas de tratamento da insuficiência coronariana. Grande número de ensaios clínicos randomizados foi publicado comparando os dois procedimentos^1-44.

À luz desses estudos parece haver ligeira superioridade da cirurgia sobre a angioplastia na capacidade de reduzir sintomas anginosos e significativa diferença na capacidade de evitar novos procedimentos de revascularização. Parece não haver diferenças no tocante à ocorrência de infarto do miocárdio com desenvolvimento de onda Q. Dúvidas persistem nas diferenças de resultados em termos de mortalidade a curto e a longo prazo, na diferença de mortalidade em diabéticos, bem como na diferença de risco de acidente vascular cerebral (AVC) e na capacidade dos stents farmacológicos eliminarem as diferenças no que toca à necessidade de nova revascularização.

O objetivo do presente trabalho foi efetuar uma revisão, agregando resultados de ensaios clínicos randomizados que compararam angioplastia transluminal coronariana percutânea com cirurgia de revascularização miocárdica.

Métodos

Seleção e características dos estudos

Foram pesquisados na base de dados MEDLINE e COCHRANE os ensaios randomizados que compararam angioplastia transluminal coronariana percutânea com cirurgia de revascularização miocárdica, publicados no período entre janeiro de 1986 a março de 2010. O mês de Janeiro de 1986 foi escolhido como data inicial devido ao fato da angioplastia ter começado a se estabelecer como método terapêutico a partir de meados dos anos 1980.

Na pesquisa nas bases de dados foram utilizados os seguintes termos: angioplasty transluminal percutaneous coronary, coronary artery bypass surgery, coronary stents e randomized controlled trial. Após o levantamento inicial, que considerou também referências bibliográficas de trabalhos de revisão sobre o assunto e de meta-análises, utilizamos o seguinte critério para incluir o estudo na revisão: ele deveria ser randomizado, comparar CRM com ICP, ter seguimento de pelo menos seis meses e ter sido publicado em revistas internacionais classificadas como Qualis A ou B pela Capes (Coordenação de Aperfeiçoamento de Pessoal de Ensino Superior do Ministério da Educação do Brasil). Trabalhos resultantes de estudos observacionais (registros) não foram considerados. Identificamos um total de 26 estudos randomizados que satisfaziam as exigências: RITA^1,2, ERACI^3,4, EAST^5-7, GABI^8,9, CABRI^10,11, TOULOUSE¹², BARI^13-16, MASSI^17,18, LAUSANNE^19,20, ERACI II^21,22, MASS II^23-25, AWESOME^26,27, OCTOSTENT²⁸, LEIPZIG²⁹, SIMA^30,31, Drenth e cols.³², SOS^33,34, ARTS^35,36, LEMANS³⁷, SYNTAX³⁸, MYOPROTECT³⁹, Hong e cols.⁴⁰, Kim e cols.⁴¹, Cisowski e cols.⁴², AMIST⁴³ e CÁRDia⁴⁴ .

Os ensaios foram classificados em dois tipos de estudo: estudos em lesão única proximal de descendente anterior e estudos em multiarteriais. Todos os ensaios que incluíram doentes biarteriais, triarteriais ou tronco de coronária esquerda, mesmo que tenham incluído também uniarteriais, foram classificados em multiarteriais. Anatomia complexa foi critério de exclusão em todos os estudos, exceto o SYNTAX. Tronco foi também geralmente critério de exclusão, com exceção do ERACI II, do SYNTAX e do LEMANS. Revascularização cirúrgica prévia foi critério de exclusão em todos os estudos, com exceção do AWESOME. Esse estudo diferiu dos demais por ter envolvido pacientes com elevado risco cirúrgico e ter apresentado fração de ejeção média significativamente abaixo da normal. Apesar disso não foi excluído da revisão, visto que a indicação de revascularização miocárdica para os tipos de pacientes nele incluídos constitui situação cada vez mais comum na prática cardiológica. O MYOPROTECT foi excluído da revisão por apresentar mortalidade precoce extremamente elevada (mais de três desvios padrões acima da média), tanto da ICP quanto da CRM, e por ter testado uma forma especial de intervenção percutânea, utilizando retroperfusão.

Desfechos avaliados

Os desfechos de interesse foram: mortalidade, AVC e nova revascularização. A mortalidade foi dividida em precoce, intermediária e tardia. A mortalidade precoce foi definida como o percentual de mortes ocorridas até 30 dias pós-procedimento, somados às mortes pré-procedimento^2,8,33,35,38. A mortalidade precoce foi fornecida por 23 estudos. Nos dois em que não foi fornecida^35,38 ela pôde ser estimada através das curvas de sobrevida^35,38 e colocada nas tabelas, mas não foi incluída no cálculo do total de eventos (por não serem números efetivamente publicados). A mortalidade intermediária foi definida como o percentual de mortes reportadas até um período máximo de 2,5 anos pós-procedimento. Em 19 estudos foi reportada a mortalidade de 1 ano, em 2 de 6 meses^40,42, em 1 de 1,5 anos²¹ e em 2 de 2,5 anos^1,19. Isso representou um acompanhamento médio de 1,1 ano. A mortalidade tardia foi definida como a mortalidade reportada como ocorrendo 2,6 anos ou mais pós-procedimento. Ela foi fornecida em 18 estudos. Em 12 foi reportada a mortalidade de 5 anos, em dois a mortalidade de 3 anos^4,26, em dois, de 4 anos^32,11 , em um, de 6,5 anos¹, em um, de 7,5 anos²⁸ e em um, de 10 anos³¹. Isso representou um acompanhamento médio de 4,9 anos. A incidência de AVC foi reportada em 20 estudos. Em 19 foram considerados os AVCs ocorridos até 30 dias pós-procedimento e em um³⁸, os ocorridos até um ano pós-procedimento. A incidência de nova revascularização levou em conta os resultados da primeira publicação, geralmente um ano pós-procedimento, período em que é mais frequente a necessidade de novas angioplastias. Em 19 casos foram considerados os resultados de um ano e em um caso, os resultados de 6 meses⁴⁰ . A partir dos dados reportados foi calculada a incidência de nova revascularização por procedimento alternativo: cirurgia em pacientes do grupo ICP e angioplastia em pacientes do grupo CRM.

Coleta dos dados e síntese dos resultados

Os resultados reportados em cada estudo foram colhidos por dois investigadores e a incidência de eventos (mortes e AVC) foi colocada em uma planilha Excel. Os dados dos estudos em multiarteriais foram agregados como se se tratasse de um único estudo. O mesmo foi feito com os dados dos estudos em uniarteriais. Isso pareceu justificável pelos seguintes motivos: a) os desfechos avaliados (mortalidade e AVC) são variáveis bem definidas; b) todos os estudos, quer em multiarteriais, quer em uniarteriais, tinham um elemento em comum: os pacientes tinham indicação de revascularização, a qual poderia ser feita por tanto por ICP quanto por CRM; c) apesar dos progressos na cardiologia intervencionista, não existem provas definitivas de que stents tenham reduzido a mortalidade ou a incidência de AVC quando comparados à ICP com balão.

Foram avaliados separadamente os resultados em diabéticos, reportados em nove estudos, assim como os de pacientes com lesão de tronco, reportados em dois estudos. Foi feita também uma avaliação dos resultados de estudos da era balão e da era stent. A comparação entre os estudos, de forma individual e na totalidade dos resultados, foi feita também através de um "índice de risco relativo", que levou em conta a sobrevida livre de eventos. Esse índice foi obtido dividindo-se o percentual de pacientes livres do evento do grupo angioplastia pelo percentual de pacientes livres do evento do grupo cirurgia. Não foi escolhida como fonte de comparação entre os estudos a razão de chances (odds ratio) nem o risco relativo convencional (de ocorrência de eventos) em função da existência de significativo número de ensaios em que o número de desfechos foi zero.

Resultados

Dos 25 estudos, nove pertenciam a era balão^1-20, 15 a era stent^21-44, e um, a um período intermediário (AWESOME), sendo esse último classificado como estudo da era stent. Nove estudos avaliaram exclusivamente doentes com lesão única proximal da descendente anterior. Nos estudos classificados como multiarteriais, 11 avaliaram doentes bi- ou triarteriais; um avaliou obstrução de tronco (LEMANS), um, doentes triarteriais ou tronco (SYNTAX); três incluíram uniarteriais, biarteriais ou triarteriais (ARTS, RITA e OCTOSTENT). Na maioria dos estudos a cirurgia utilizou circulação extracorpórea (CEC). Três estudos em multiarteriais (ARTS, SYNTAX e SOS) utilizaram também cirurgia sem CEC em pacientes selecionados, de acordo com a prática do local. No OCTOSTENT utilizou-se apenas cirurgia sem CEC. Dos nove estudos de obstrução única proximal DA, em três deles a cirurgia foi realizada com CEC e esternotomia mediana (MASS I, LAUSANNE e SIMA). Nos demais realizou-se cirurgia sem CEC e usando toracotomia lateral esquerda (Drenth e cols.³², Leipzig, Hong e cols.⁴⁰, Kim e cols.⁴¹, Cisowski e cols.⁴² e AMIST). A lesão de tronco foi critério de exclusão em 22 estudos. Ela esteve presente no ERACI II (5% dos pacientes), no SYNTAX (39% dos pacientes), e no LEMANS (100% dos pacientes). Apenas quatro estudos (SYNTAX, LEMANS, CARDia e Hong e cols.⁴¹) empregaram stents farmacológicos. Um estudo avaliou apenas diabéticos (CÁRDia).

Os 25 estudos envolveram 12.305 pacientes, sendo que 11.103 pertenciam a estudos em multiarteiriais e 1.212 a estudos em lesão única de descendente anterior. Nos 16 estudos em multiarteirais, os biarteriais predominaram na era balão e os triarteriais e/ou lesão de tronco predominaram na era stent. No total dos estudos em multiarteirais mais de 50% dos pacientes apresentavam doença de três vasos ou tronco e mais de 50% apresentavam obstrução proximal da descendente anterior (nos estudos que reportaram esta informação). Fração de ejeção diminuída esteve quase sempre ausente nos estudos em lesão única de DA. Nos estudos em multiarteriais ela se mostrou diminuída em 18% dos pacientes (não considerando o CABRI e o AWESOME que não reportaram esta informação). A média de idade dos pacientes foi de 62 anos e 77% eram do sexo masculino. A idade média mostrou tendência a ser maior nos estudos em multiarteriais que nos em lesão única de DA e na era stent que na era balão. Diabete melito esteve presente em 20% dos pacientes. A grande maioria dos pacientes era sintomática (angina estável, instável ou infarto prévio). Angina instável esteve presente com uma frequência que variou de 0% (estudos MASS) a 92% (estudo ERACI II).

Os resultados dos estudos em multiarteriais estão representados nas tabelas 1 e nas figuras 1 a 3. A mortalidade precoce foi menor com a ICP na maioria dos estudos. A agregação dos resultados foi favorável à angioplastia. (1,2 versus 2%: p = 0,034). Mas ao incluirmos os resultados estimados do ARTS e do SYNTAX as diferenças ficaram menos significativas (1,3% versus 1,7%). Os estudos que mais contribuíram para o pior resultado da cirurgia foram o ERACI, o AWESOME e o ERACI II, que incluíram um substancial número de pacientes agudos.

No que toca à mortalidade intermediária os resultados foram idênticos (3,8 versus 3,8%). Na mortalidade tardia houve tendência a melhor resultado da cirurgia (10,5% versus 9,6%: p = 0,07). Essa diferença deveu-se exclusivamente a estudos da era balão, tendendo a inverter-se na era stent (9,6 versus 9,9%). Apenas um estudo da era stent mostrou menor mortalidade com a cirurgia (SOS), devido a uma maior mortalidade por câncer no grupo ICP. A figura 2 mostra acentuada heterogeneidade dos resultados com tendência a superioridade da cirurgia na era balão e da angioplastia na era stent.

No que toca à incidência de AVC ela foi maior com a cirurgia (0,7% versus 1,65%: p < 0,001), com praticamente todos os estudos em multiarteriais mostrando melhor resultado com a angioplastia (fig. 3).

Os dados dos estudos em lesão única de D.A. estão mostrados na tabela 2. Na agregação de resultados não houve diferença significativa em nenhum desfecho: 0,5% versus 0,9%, para mortalidade precoce; 1,1% versus 2,4%, para mortalidade intermediária; 6,7% versus 5,5% para mortalidade tardia e 0,4% versus 0,5% para AVC.

Os dados referentes à necessidade de novas revascularizações estão mostrados na tabela 3 e na figura 4. A superioridade da cirurgia sobre a angioplastia foi consistente em 23 de 24 estudos. Mas observa-se progressiva melhora dos resultados da ICP. Nos multiarteriais a incidência de nova revascularização no grupo ICP caiu de 49% no EAST e 44% no BARI para em torno de 11% no SYNTAX e no CÁRDia. Nos pacientes com lesão única de DA ela caiu de 39,9% no MASS I para menos de 10% nos estudos recentes da era stent. A figura 4 mostra que o risco relativo de nova revascularização por procedimento alternativo (cirurgia para pacientes submetidos a ICP e angioplastia para pacientes submetidos a CRM) apresentou uma clara tendência a equalização de resultados na era stent.

Nove estudos relataram mortalidade tardia no subgrupo de diabéticos. Seis mostraram tendência favorável à cirurgia (CABRI, EAST, BARI, MASS II, ARTS e SOS), um foi neutro (ERACI II) e dois mostraram tendência favorável à angioplastia (RITA e AWESOME). Agregando-se os resultados desses estudos, a mortalidade tardia foi de 21,3% no grupo intervenção e 15,9% no grupo cirurgia.

Dois estudos mencionaram os resultados de mortalidade em um ano em lesão de tronco não protegida (tabela 4). No SYNTAX a mortalidade foi 4,2% no grupo ICP versus 4,4% no grupo CRM; Observou-se tendência a menor mortalidade por angioplastia nos pacientes com escore de SYNTAX baixo ou intermediário e tendência a maior mortalidade com a CRM em pacientes com escore de SYNTAX alto. No LEMANS a mortalidade foi de 2% no grupo ICP versus 8% no grupo CRM. Na agregação dos resultados dos dois ensaios não houve diferença significativa (3,9% versus 4,7%). Ao agregarmos os resultados do LEMANS (no qual a maior parte dos pacientes não apresentava elevada complexidade angiográfica) aos dos subgrupos de pacientes com escore baixo ou intermediário do SYNTAX, notou-se uma tendência claramente favorável à angioplastia (1,1% versus 5,6%).

Discussão

Várias revisões⁴⁵, meta-análises de estudos randomizados^46-48, e um importante estudo colaborativo⁴⁹, foram publicadas comparando ICP com CRM. O principal diferencial da presente revisão é o número de estudos e de pacientes avaliados. Isso decorreu do fato de termos considerado faixas de ocorrência e não instantes rigidamente fixados. Além disso, foram acrescentados estudos recentes que utilizaram stents farmacológicos^39,45 e envolveram grande número de pacientes.

A tendência a maior mortalidade precoce encontrada nos pacientes cirúrgicos está em consonância com o Registro do Estado de Nova York⁵⁰ que mostrou mortalidade hospitalar com a cirurgia mais de duas vezes maior que a dos pacientes submetidos à angioplastia (0,68% versus 1,75%). Cabe lembrar que o pior resultado da cirurgia deveu-se a estudos da era balão e, na era stent, aos estudos ERACI II e AWESOME, os quais envolveram substancial número de doentes agudos ou de elevado risco cirúrgico. Além disso, houve importante melhora dos resultados cirúrgicos nos ensaios clínicos mais recentes^34,35,38. No tocante à mortalidade intermediária, os dados do presente estudo são extremamente consistentes e estão em consonância com tudo que foi até agora publicado: nenhuma diferença em um ano entre angioplastia e cirurgia. Também não foi encontrada diferença significativa na mortalidade tardia, particularmente na era stent, o que também foi sugerido em recente revisão sistemática⁴⁸, estando porem em desacordo com uma meta-análise mais antiga⁴⁶. Esta mostrou uma tendência progressivamente favorável à cirurgia à medida que a comparação ficava mais tardia. Existe uma possível explicação para essa discrepância: quando se comparou a angioplastia com a cirurgia na referida meta-análise, à medida que a avaliação se tornava mais tardia passava a incluir maior número de estudos da era balão, nos quais havia tendência a superioridade da cirurgia. Na presente revisão, em que foi incluído um número mais significativo de estudos da era stent, a superioridade tardia dos resultados cirúrgicos tendeu a diminuir.

Nota-se também a similaridade de resultados nos estudos de lesão única proximal da DA, havendo inclusive uma tendência a superioridade da angioplastia na era stent, pelo menos em termos de mortaldade precoce e intermediária. Isto torna a ICP, por ser menos invasiva, a forma preferencial de revascularização em pacientes com lesão única proximal de DA, a menos que a anatomia seja claramente inadequada. A possibilidade de que técnicas cirúrgicas menos invasivas possam melhorar os resultados cirúrgicos não é corroborada na presente revisão. A análise individualizada dos dados das tabelas 2 e 3 sugere que os melhores resultados da cirurgia foram justamente nos estudos que utilizaram técnica convencional, ou seja, esternotomia mediana e cirurgia com CEC (SIMA, LAUSANNE e MASS I), e os piores nos que utilizaram técnicas minimamente invasivas.

A tendência a maior incidência de AVC no grupo cirúrgico já havia sido sugerida anteriormente⁴⁸, tendo alcançado significância estatística no SYNTAX. Por agrupar maior número de pacientes e acrescentar os resultados do SYNTAX e do CÁRDia, a superioridade da angioplastia na presente revisão é inquestionável. Curiosamente não encontramos diferença na ocorrência de AVC nos estudos em pacientes com lesão única de DA, nem no OCTOSTENT, que utilizou cirurgia sem CEC. Além de uma menor manipulação da aorta e do uso quase exclusivo de mamária poderíamos aventar como explicação para o fato um menor grau de aterosclerose nesses pacientes.

As diferenças de resultados entre os estudos randomizados, quando avaliados em meta-análises ou revisões como esta, e os dados de registros, como o de New York⁵⁰, merecem ser comentadas. Registros, ao contrário das meta-análises, mostraram quase uniformemente maior mortalidade da angioplastia nos subgrupos considerados classicamente como cirúrgicos (3 vasos, 2 ou 3 vasos com obstrução da DA proximal, má função ventricular). No entanto, registros apresentam vieses de seleção que mesmo as melhores técnicas estatísticas não conseguem eliminar. A possibilidade classicamente levantada de que a ausência de diferenças na mortalidade nos estudos randomizados seja decorrente de um predomínio de biarteriais sobre os triarteriais e do pequeno número de pacientes com má função ventricular ou obstrução proximal da DA^51,52 não nos parece válida atualmente, pelas seguintes razões: a) a maioria dos pacientes definidos como multiarteriais na presente revisão foi constituída de triarteriais ou obstrução de tronco, principalmente na era stent; b) houve tendência favorável à angioplastia nos estudos envolvendo pacientes com lesão única proximal da DA; c) mais de 50% dos multiarteriais apresentavam obstrução da DA proximal e cerca de 18% apresentavam má função ventricular, um número não insignificante; d) vários trabalhos sugerem que as condições de triarterial, de apresentar má função ventricular (em não diabéticos) e de apresentar obstrução de DA proximal não comprometem os resultados da ICP quando comparada com a cirurgia^14,22,23,49.

Na comparação entre a era balão e a era stent chama a atenção a melhora dos resultados de mortalidade tardia da angioplastia na era stent, apesar da maior complexidade dos pacientes. As hipóteses para essa melhora seriam o progresso na técnica intervencionista, permitindo tratar de forma mais completa e segura as obstruções, assim como progressos no tratamento clínico, pelo uso mais liberal de antiadesivos plaquetários e hipolipemiantes. Os piores resultados cirúrgicos nos primeiros estudos da era stent, particularmente em relação à mortalidade precoce, podem ser atribuídos à gravidade dos pacientes, devendo-se principalmente aos estudos ERACI II e AWESOME. Ao considerarmos os resultados dos estudos mais recentes, inclusive os estimados através das curvas de sobrevida, o que surpreende é uma mortalidade operatória extremamente baixa, abaixo de 1%^34,35,38. A explicação para a queda na mortalidade cirúrgica nos estudos recentes seria, à primeira vista, a melhora dos cuidados pós-operatórios e das técnicas cirúrgicas, incluindo o uso de cirurgia sem CEC em pacientes selecionados. Uma explicação alternativa seria o fato da maior parte dos pacientes com angina instável de alto risco, no passado, frequentemente tratados por cirurgia, estar sendo hoje encaminhada para angioplastia.

A superioridade da CRM sobre a ICP no que toca à incidência de novas revascularizações é amplamente reconhecida. Contudo, existe um inexorável viés de origem nessa comparação. A ICP não compromete revascularizações futuras, sejam elas uma nova angioplastia ou uma primeira cirurgia, o mesmo não acontecendo com a CRM. Essa última impossibilita frequentemente futuras angioplastias e aumenta significantemente o risco em caso de nova revascularização cirúrgica. No presente trabalho, apesar da evidente superioridade da cirurgia, pode-se observar uma progressiva melhora da angioplastia na era stent, culminando com os excelentes resultados com o uso de stents farmacológicos. Essa melhora é particularmente marcante quando consideramos apenas o risco de nova revascularização por procedimentos alternativos, no qual houve tendência à equalização de resultados na era stent.

A lesão de tronco não protegida constituía, até pouco tempo, uma indicação definitiva para cirurgia. A existência de comprovado beneficio da cirurgia na redução da mortalidade e o caráter catastrófico de uma oclusão aguda durante a intervenção percutânea, levam-na a ser classificada como indicação preferencial para cirurgia nas diretrizes, sendo a angioplastia caracterizada durante muito tempo como indicação tipo III e só recentemente como IIb⁵³. Aos resultados do SYNTAX e do LEMANS, assim como a tendência à superioridade da angioplastia em pacientes com escore de SYNTAX inferior a 33⁵⁴ apontam para a necessidade de melhor classificação da intervenção percutânea em lesão de tronco, desde que os pacientes apresentem boa anatomia para intervenção.

Pacientes multiarteriais diabéticos constituem, de maneira geral, indicação preferencial para cirurgia. As evidências contrárias à angioplastia em diabéticos têm origem na era balão, a partir dos achados ocasionais do estudo BARI. Seus investigadores avaliaram um subgrupo de 343 diabéticos e encontraram uma mortalidade tardia de 34,5% para a intervenção com balão e 19,4% para a cirurgia p = 0,03). Diabete em multiarteriais constitui, desse modo, indicação preferencial para cirurgia nas diretrizes, sendo a angioplastia nesses pacientes classificada como IIb.

No presente trabalho, que incluiu a taxa de mortalidade em 4 anos do CABRI e em 5 anos do ARTS e do SOS, o agrupamento de resultados foi favorável à cirurgia, com tendência à significância estatística. É provável que essa tendência à superioridade esteja relacionada simplesmente com o grau de complexidade das lesões, não valendo para todos os diabéticos. Em particular ela não se aplicaria a pacientes com angina instável (estudo ERACI II), a pacientes de alto risco cirúrgico (estudo AWESOME) e a pacientes em que se empreguem com maior frequência enxertos venosos (estudo RITA). Além disso, nenhum desses nove estudos utilizou stents farmacológicos. O SYNTAX e o CÁRDia, primeiros estudos a comparar stents farmacológicos com cirurgia em diabéticos, não mostraram diferença na mortalidade em um ano. Mas como são resultados iniciais, uma resposta definitiva terá de aguardar os resultados tardios desses estudos, assim como os do FREEDOM.

Conclusão

Os dados da presente revisão confirmam a tendência atual de considerar a complexidade das lesões e não o número ou tipo de vasos envolvidos, ou mesmo a má função ventricular, como o principal fator para escolha entre os procedimentos de revascularização miocárdica.

Potencial Conflito de Interesses

Declaro não haver conflito de interesses pertinentes.

Fontes de Financiamento

O presente estudo não teve fontes de financiamento externas.

Vinculação Acadêmica

Não há vinculação deste estudo a programas de pós-graduação.

Correspondência:

Pedro José Negreiros de Andrade

Rua Francisco Holanda, 992/1101 - Dionísio Torres

60130-040 - Fortaleza, CE - Brasil

E-mail:

pedroneg@cardiol.br,

pedroneg@gmail.com

Artigo recebido em 14/05/10; revisado recebido em 23/08/10; aceito em 24/09/10.

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Clinical Update

Coronary angioplasty versus CABG: review of randomized

We carried out a review that included results of randomized trials that made a comparison between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The 25 selected trials involved 12,305 patients, 11,103 of whom were from studies in patients with multi-vessel disease and 1,212 were from studies in patients with single lesion of the left anterior descending (LAD). In the studies of multi-vessel disease patients, the PCI showed a trend towards lower early mortality (1.2% versus 2%) and lower incidence of stroke: 0.7% versus 1.65%. There was no difference in the intermediate mortality (3.8% versus 3.8%). There was a trend towards the superiority of CABG in late mortality (10.5% versus 9.6%). The difference was exclusively due to "balloon era" studies, with a trend towards an inversion in the "stent era" (9.6% versus 9.9%). In studies of single lesion of LAD, there was no significant difference in any endpoint. The aggregation of results from nine studies that assessed late mortality in diabetic patients showed a difference in favor of surgery (21.3% versus 15.9%). Two studies that evaluated main coronary artery disease did not show a significant difference in mortality at one year (3.9% versus 4.7%). The incidence of repeat revascularization was consistently higher in PCI, despite the progressive improvement in results in the stent era.

Angioplasty transluminal percutaneous coronary coronary artery bypass myocardial revascularization meta-analysis

IMAGE

Coronary angioplasty versus CABG: review of randomized

Pedro José Negreiros de Andrade^I; Marta Maria das Chagas Medeiros^II; Antonio Thomaz de Andrade^III; Antonio Augusto Guimarães Lima^I

^IServiço de Cardiologia do Hospital Universitário Walter Cantidio da Universidade Federal do Ceará

^IIDepartamento de Medicina Clinica da Faculdade de Medicina da Universidade Federal do Ceará

^IIIFortaleza, CE; Instituto de Cardiologia Dante Pazzanese, São Paulo, SP - Brazil

Mailing address

ABSTRACT

Keywords: Angioplasty, transluminal, percutaneous coronary; coronary artery bypass; myocardial revascularization; meta-analysis.

Introduction

Both the percutaneous coronary intervention (angioplasty or PCI) and the coronary artery bypass grafting (surgery or CABG) are well accepted alternative treatments for coronary insufficiency. A large number of randomized controlled trials comparing the two procedures were published^1-44.

In light of these studies, there seems to be slight superiority of surgery over angioplasty in the ability to reduce anginal symptoms, and a significant difference in the ability to avoid new revascularization procedures. There seems to be no difference with respect to the occurrence of myocardial infarction with development of Q wave. There are still some doubts about the differences in outcomes in terms of mortality in the short term and in the long term, the difference in mortality in diabetics, as well as the difference in risk of cerebrovascular accident (CVA) and the capacity of drug-eluting stents to eliminate the differences regarding the need for repeat revascularization.

The aim of this study was to carry out a review, by adding the results of randomized controlled trials that compared percutaneous transluminal coronary angioplasty with coronary artery bypass surgery.

Methods

Selection and characteristics of the studies

In the MEDLINE and CHOCHRANE database, we investigated randomized trials that compared percutaneous transluminal coronary angioplasty with coronary artery bypass surgery, published between January 1986 and March 2010. The month of January, 1986, was chosen as the start date because angioplasty started to establish itself as a therapeutic method in the mid 1980s.

In the investigation of databases, the following terms were used: angioplasty transluminal percutaneous coronary, coronary artery bypass surgery, coronary stents and randomized controlled trial. After the initial survey, which also considered references to review papers on the subject and meta-analyses, we used the following criteria to include studies in the review: to be randomized, to compare CABG with PCI, to have a follow-up of at least six months and to have been published in international journals rated as Qualis A or B by CAPES (Coordination for the Improvement of Higher Education Personnel of the Brazilian Ministry of Education). Papers resulting from observational studies (records) were not considered. We identified a total of 26 randomized studies that met the requirements: RITA^1,2, ERACI^3,4, EAST^5-7, GABI^8,9, CABRI^10,11, TOULOUSE¹², BARI^13-16, MASSI^17,18, LAUSANNE^19,20, ERACI II^21,22, MASS II^23-25, AWESOME^26,27, OCTOSTENT²⁸, LEIPZIG²⁹, SIMA^30,31, Drenth et al³², SOS^33,34, ARTS^35,36, LEMANS³⁷, SYNTAX³⁸, MYOPROTECT³⁹, Hong et al⁴⁰, Kim et al⁴¹, Cisowski et al⁴², AMIST⁴³ and CÁRDia⁴⁴.

The trials were classified in two types of study: studies in isolated lesions of proximal left anterior descending coronary artery and studies in multivessel disease. All trials that included patients with two-vessel disease, triple-vessel disease or left left main coronary artery, even if they also included single-vessel disease patients, were classified as multi-vessel disease. Complex anatomy was an exclusion criterion in all studies, except SYNTAX. Main coronary artery was usually also an exclusion criterion, except for ERACI II, SYNTAX and LEMANS. Prior CABG was an exclusion criterion in all studies, except for AWESOME. This study differed from the others because it involved patients at high surgical risk, and because it presented a mean ejection fraction that was significantly below normal. In spite of that, it was not excluded from review, since the indication for CABG for the types of patients included in it has been increasingly common in cardiology. MYOPROTECT was excluded from the review because it had extremely high early mortality (more than three standard deviations above the mean), both for PCI and CABG, and because it had tested a special form of percutaneous intervention, using retrograde perfusion.

Assessed endpoints

The endpoints of interest were: mortality, stroke and repeat revascularization. Mortality was divided into early, intermediate and late. Early mortality was defined as the percentage of deaths occurring within 30 days after the procedure, added to pre-procedure deaths^2,8,33,35,38. Early mortality was provided by 23 studies. In the two in which it was not given^35,38, it could be estimated by the survival curves^35,38 and then it was placed in the tables, but it was not included in the calculation of the total of events (since they referred to numbers that were not actually published). The intermediate mortality was defined as the percentage of deaths reported up to a maximum period of 2.5 years after the procedure. In 19 studies, the mortality of 1 year was reported. In 2 studies, the mortality of 6 months^40,42 was reported. In one study, the mortality of 1.5 year was reported²¹ and in 2 studies, the mortality of 2.5 years was reported^1,19. This represented an average follow-up of 1.1 year. Late mortality was defined as mortality reported as having occurred 2.6 years or more after the procedure. It was provided in 18 studies. In 12 studies, the mortality of 5 years was reported; in two, the mortality of 3 years^4,26; in two, of years^32,11; in one, of 6.5 years¹, in one, of 7.5 years²⁸; and in one, of 10 years³¹. This represented an average follow-up of 4.9 years. The incidence of stroke was reported in 20 studies. In 19 studies, strokes that occurred within 30 days after the procedure were considered and, in one study, the strokes that occurred up to one year after the procedure were considered. The incidence of repeat revascularization took into account the results of the first publication, usually one year after the procedure, a period when the need for further angioplasties is more frequent. In 19 cases, the results of one year were considered and, in one case, the results of 6 months⁴⁰. Based on the data reported, we calculated the incidence of repeat revascularization by an alternative procedure: surgery in patients of the PCI group and angioplasty in patients of the CABG group.

Data collection and summary of results

The results reported in each study were collected by two researchers and the incidence of events (deaths and stroke) was placed in an Excel spreadsheet. Data from studies of patients with multi-vessel disease were grouped as if they referred to a single study. The same was done with data from studies in patients with single-vessel disease. This seemed to be justifiable for the following reasons: a) the assessed endpoints (mortality and stroke) are well-defined variables; b) all studies, whether in multi-vessel disease patients, or in single-vessel disease patients, had one element in common: patients were referred to revascularization, which could be carried out either by PCI or by CABG; c) despite the progress in interventional cardiology, there is no definitive evidence that stents have reduced the mortality or incidence of stroke when compared with PCI with balloon.

The results in diabetics, reported in nine studies, as well as those of patients with left main coronary artery disease, reported in two studies, were evaluated separately. The results of studies of the balloon era and stent era were also evaluated. The comparison between studies, both individually and in all of the results, was also made by means of a "relative risk index," which took into account the event-free survival. This index was obtained by dividing the percentage of event-free patients from the angioplasty group by the percentage of event-free patients from the surgery group event. Neither the odds ratio nor the conventional relative risk (of event occurrence) were chosen as a source a comparison between the studies, due to the existence of a significant number of trials where the number of endpoints was zero.

Results

Out of the 25 studies, nine belonged to the balloon era^1-20, 15 to the stent era, and one to an intermediate period (AWESOME)^21-44. This last one was classified as a study from the stent era. Nine studies assessed only patients with single proximal lesion of the anterior descending coronary. In studies classified as multi-vessel disease, 11 evaluated patients with two-vessel or three-vessel disease; one evaluated an obstruction of the main coronary artery (LEMANS); one assessed patients with triple-vessel disease or main coronary artery disease (SYNTAX); three included patients with single-vessel, two-vessel or three-vessel disease (ARTS, RITA and OCTOSTENT). In most studies, cardiopulmonary bypass (CPB) was used in the surgery. Three studies in patients with multi-vessel disease (ARTS, SYNTAX and SOS) also used off-pump surgery in selected patients, according to local practice. In OCTOSTENT, only off-pump surgery was used. In three of the nine studies of single proximal obstruction of the anterior descending artery, the surgery was performed with CPB and median sternotomy (MASS I, LAUSANNE and SIMA). In the others, off-pump CABG was performed using left lateral thoracotomy (Drenth et al³², Leipzig, Hong et al⁴⁰, Kim et al⁴¹, Cisowski et al⁴² and AMIST). Main coronary artery disease was an exclusion criterion in 22 studies. The main coronary artery disease was present in ERAC II (5% of patients), in SYNTAX (39% of patients), and in LEMANS (100% of patients). Only four studies (SYNTAX, LEMANS, CARDia and Hong et al⁴¹) used drug-eluting stents. One study evaluated only diabetics (CÁRDia).

The 25 studies involved 12,305 patients, 11,103 of whom belonged to studies in patients with multi-vessel disease and 1,212 to studies in a single lesion of the left anterior descending artery. In the 16 studies in patients with multi-vessel disease, the two-vessel disease was predominant in the balloon era and the three-vessel disease or main coronary artery disease was predominant in the stent era. In all the studies with patients with multi-vessel disease, over 50% of patients had three-vessel disease or main coronary artery disease and more than 50% had proximal obstruction of the left anterior descending coronary artery (in studies that reported this information). Decreased ejection fraction was almost always absent in studies with a single lesion of LAD coronary artery. In the studies in patients with multi-vessel disease, it was decreased in 18% of the patients (not considering CABRI and AWESOME, which did not report this information). The average patient age was 62 years and 77% were male. The mean age tended to be higher in studies with patients with multi-vessel disease than in single lesion of LAD coronary artery. The mean age was also higher in stent era than in the balloon era. Diabetes mellitus was present in 20% of patients. The vast majority of patients were symptomatic (unstable, stable angina or previous infarction). Unstable angina was present at a frequency that ranged from 0% (MASS studies) to 92% (ERAC II study).

The results of studies in multi-vessel disease patients are presented in table 1 and in figures 1 to 3. Early mortality was lower with PCI in most studies. The aggregation of results was favorable to angioplasty. (1.2 versus 2%: p = 0.034). But when we include the estimated results of ARTS and SYNTAX, the differences were less significant (1.3% versus 1.7%). The studies that contributed most to the worst result of the surgery were ERACI, AWESOME and ERACI II, which included a substantial number of acute patients.

With regard to the intermediate mortality, the results were identical (3.8 versus 3.8%). In the late mortality, there was a trend towards a better outcome of surgery (10.5% versus 9.6%: p = 0.07). This difference was exclusively due to "balloon era" studies, with a trend towards an inversion in the "stent era" (9.6% versus 9.9%). Only one study of the stent era showed lower mortality with surgery (SOS), due to a higher cancer mortality in the PCI group. Figure 2 shows marked heterogeneity of results with a tendency to superiority of surgery in the balloon era, and of angioplasty in the stent era.

The incidence of stroke was higher with surgery (0.7% versus 1.65%: p < 0.001), with virtually all studies in patients with multi-vessel disease showing improved outcome with angioplasty (Fig. 3).

The data of studies in single lesion of LAD coronary artery are shown in table 2. In the aggregation of results, there was no significant different in any endpoint: 0.5% versus 0.9%, for early mortality; 1.1% versus 2.4%, for intermediate mortality; 6.7% versus 5.5% for late mortality; and 0.4% versus 0.5% for stroke.

The data regarding the need for further revascularization are shown in table 3 and figure 4. The superiority of surgery over angioplasty was consistent in 23 of 24 studies. However, there has been gradual improvement in the results of PCI. In studies of multi-vessel disease patients, the incidence of repeat revascularization in the PCI group dropped from 49% in EAST and 44% in BARI to around 11% in SYNTAX and in CÁRDia. In patients with single lesions of LAD coronary artery, it dropped from 39.9% in MASS I to less than 10% in recent studies of the stent era. Figure 4 shows that the relative risk of new revascularization by means of an alternative procedure (surgery for patients undergoing PCI and angioplasty for patients undergoing CABG) showed a clear tendency to equalization of outcomes in the stent era.

Nine studies reported late mortality in the diabetic subgroup. Six showed a trend in favor of surgery (CABRI, EAST, BARI, MASS II, ARTS and SOS), one was neutral (ERACI II) and two showed a trend in favor of angioplasty (RITA and AWESOME). By aggregating the results of these studies, the late mortality was 21.3% in the intervention group and 15.9% in the surgery group.

Two studies have mentioned the results of mortality at one year in unprotected main coronary artery disease (Table 4). In SYNTAX, the mortality was 4.2% in the PCI group versus 4.4% in the CABG group. There was a trend towards lower mortality with angioplasty in patients with low or intermediate SYNTAX score, and a tendency towards higher mortality with CABG in patients with high SYNTAX score. In LEMANS, the mortality was 2% in the PCI group versus 8% in the CABG group. When the results of the two trials were aggregated, there was no significant difference (3.9% versus 4.7%). When we added the results of LEMANS (in which most of the patients did not show high angiographic complexity) to those of the subgroups of patients with low or intermediate SYNTAX score, it was possible to notice a trend clearly in favor of angioplasty (1.1% versus 5.6%).

Discussion

Several reviews⁴⁵, meta-analyses of randomized trials^46-48, and a major collaborative study⁴⁹ were published comparing PCI with CABG. The main difference of this review is the number of studies and patients evaluated. This was due to the fact that we considered tracks of occurrence and not rigidly fixed moments. Furthermore, there was the addition of recent studies that used drug-eluting stents^39,45 and involved a large numbers of patients.

The trend towards higher early mortality found in surgical patients is in line with the Registries of the New York State⁵⁰, which showed that hospital mortality with surgery is more than two times higher than that of patients who underwent angioplasty (0.68% versus 1.75%). It is worth remembering that the worst outcome of the surgery was due to studies of the balloon era and, in the stent era, due to the ERACI II and AWESOME studies, which involved a substantial number of acute patients or patients at a high surgical risk. In addition, there has been significant improvement in surgical outcomes in more recent clinical trials^34,35,38. With respect to the intermediate mortality, the data from this study are highly consistent and are in line with what has been published until now: no difference at one year between angioplasty and surgery. There was also no significant difference in late mortality, particularly in the stent era, which was also suggested in a recent systematic review, but this is at odds with an older meta-analysis⁴⁶. This meta-analysis showed a progressive trend in favor of surgery as the comparison was delayed. There is a possible explanation for this discrepancy: when we compared angioplasty with surgery in such meta-analysis, the later the assessment was carried out, the more "balloon era" studies were included, in which there was a tendency to the superiority of surgery. In this review, in which a more significant number of "stent era" studies were included, the late superiority of surgical results tended to decrease.

It is also possible to note the similarity of results in studies of single proximal lesion of LAD coronary artery, even with a trend toward the superiority of angioplasty in the stent era, at least in terms of early and intermediate mortality. This makes PCI, since it is less invasive, the preferred form of revascularization in patients with single proximal lesion of LAD coronary artery, unless the anatomy is clearly inadequate. The possibility that less invasive surgical techniques may improve surgical outcomes is not corroborated in this review. A separate analysis of data from tables 2 and 4 suggests that the best results of surgery were precisely in studies using conventional techniques, that is, median sternotomy and surgery with CPB (SIMA, LAUSANNE and MASS I), and the worst ones in those that used minimally invasive techniques.

The trend towards a higher incidence of stroke in the surgical group had been suggested previously⁴⁸, and it had reached statistical significance in SYNTAX. The superiority of angioplasty in this review is unquestionable, since it groups a larger number of patients and it adds the results of SYNTAX and CÁRDia. One interesting fact was that we found no difference in the incidence of stroke in studies with patients with single lesions of LAD coronary artery, nor in OCTOSTENT, which used off-pump surgery. Besides the less intense manipulation of the aorta and the almost exclusive use of mammary artery, we could suggest, as an explanation for such fact, a lower degree of atherosclerosis in these patients.

The differences in results between the randomized studies, when evaluated in a meta-analysis or review such as this one, and the data registries, such as New York one⁵⁰, deserve to be addressed. Registries, unlike the meta-analyses, showed almost uniformly higher mortality of angioplasty in subgroups classically regarded as surgical (3 vessels, 2-3 vessels with obstruction of the proximal LAD coronary artery, poor ventricular function). However, registries showed selection bias that even the best statistical techniques can not eliminate. The possibility that has been classically raised is that the absence of differences in mortality in randomized trials is due to a predominance of two-vessel disease over three-vessel disease, and the small number of patients with poor ventricular function or proximal obstruction of LAD coronary artery^51,52 does not seem to be valid today, for the following reasons: a) most patients with multi-vessel disease, as defined in this review, consisted of patients with three-vessel disease or obstruction of left main coronary artery, especially in the stent era; b) there was a trend in favor of angioplasty in studies involving patients with single proximal lesion of LAD coronary artery; c) more than 50% of multi-vessel disease patients had obstruction of the proximal LAD coronary artery and about 18% had poor ventricular function, a number that is not insignificant; d) several studies suggest that conditions such as triple-vessel disease, poor ventricular function (in non-diabetics) and the obstruction of proximal LAD coronary artery do not compromise the results of PCI, compared with surgery^14,22,23,49.

In the comparison between the balloon era and stent era, it is worth highlighting the improvement in the late mortality results of angioplasty in the stent era, despite the greater complexity of patients. The hypothesis for this improvement would be the progress in the interventional technique, making it possible to handle, in a more complete and secure way, the obstructions, as well as the progress in clinical treatment, due to the more liberal use of lipid-lowering agents and antiplatelet agents. The worse surgical results in early studies of the stent era, particularly in relation to early mortality, can be attributed to the severity of the patients' conditions, and mainly to ERACI II and AWESOME studies. Considering the results of recent studies, including those estimated by the survival curves, the surprising fact is that the operative mortality is extremely low, below 1%^34,35,38. At first glance, the decrease in surgical mortality in recent studies could be explained by the improvement in postoperative care and surgical techniques, including the use of off-pump surgery in selected patients. An alternative explanation could be that the majority of patients with high risk unstable angina, in the past, often treated by surgery, are now being referred to angioplasty.

The superiority of CABG over PCI with respect to the incidence of new revascularization is widely recognized. However, there is an inexorable source of bias in this comparison. PCI does not compromise future revascularizations, whether they are a new angioplasty or first surgery, but the same does not happen with CABG. The latter often precludes future angioplasties and significantly increases the risk in case of new surgical revascularization. In this work, despite the clear superiority of surgery, it is possible to notice the progressive improvement of angioplasty in the stent era, culminating in excellent results with the use of drug-eluting stents. This improvement is particularly striking when we consider only the risk of new revascularization by alternative procedures, in which there was a tendency to equalization of outcomes in the stent era.

Until recently, the unprotected main coronary artery disease was a definite indication for surgery. Since surgery has proven to be beneficial for the reduction in mortality and due to the catastrophic nature of an acute occlusion during percutaneous intervention, surgery has been classified as the preferred indication for main coronary artery lesion in the guidelines, with angioplasty being characterized for a long time as type-III indication and only recently as a type IIb⁵³. The results of SYNTAX and LEMANS, as well as the trend towards the superiority of angioplasty in patients with SYNTAX score below 33⁵⁴, point to the need for a better classification of percutaneous coronary intervention in a main coronary artery disease, provided that the patients' anatomy is good for the intervention.

In general, surgery is the preferred indication for diabetic patients with multi-vessel disease. The evidence against angioplasty in diabetic patients comes from the balloon era, based on occasional findings of the BARI study. Its researchers evaluated a subgroup of 343 diabetic patients and found a late mortality of 34.5% for intervention with balloon and 19.4% for surgery (p = 0.03). Thus, surgery is the preferred indication, in the guidelines, for diabetes in patients with multi-vessel disease, with angioplasty in such patients being classified as IIb.

In this study, which included the mortality rate in 4 years of CABRI and in 5 years of ARTS and SOS, the aggregation of results was favorable to surgery, with a tendency to statistical significance. This trend towards superiority is likely to be related simply to the complexity degree of the lesions, not being valid for all diabetics. In particular, it would not apply to patients with unstable angina (ERACI study II), patients at high surgical risk (AWESOME study) and patients that undergo vein grafting procedures more frequently (RITA study). Moreover, none of these nine studies used drug-eluting stents. SYNTAX and CÁRDia, the first studies that compared drug-eluting stents with surgery in diabetic patients, showed no difference in mortality at one year. However, since they are initial results, a definitive answer must wait for the late results of these studies, as well as for those of the FREEDOM study.

Conclusion

The data from this review confirm the current trend towards considering the complexity of the lesions and not the number or type of vessels involved, or even the poor ventricular function, as the main factor for choosing between the revascularization procedures.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Sources of Funding

There were no external funding sources for this study.

Study Association

This study is not associated with any post-graduation program.

References