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Heart 89:967-970 doi:10.1136/heart.89.9.967
  • Editorial

Revascularisation for acute coronary syndromes: PCI or CABG?

  1. J Gunn1,
  2. D P Taggart2
  1. 1Cardiovascular Research Group, University of Sheffield and Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
  2. 2Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Oxford, UK
  1. Correspondence to:
    Dr Julian Gunn, Cardiovascular Research Group, University of Sheffield and Sheffield Teaching Hospitals NHS Trust, Herries Road, Sheffield S5 7AU, UK;
    j.gunn{at}sheffield.ac.uk

    Recent advances in both percutaneous coronary intervention and coronary artery bypass grafting emphasise the need for new randomised trials addressing acute coronary syndromes specifically, including a high proportion of patients with truly representative disease

    We are in the midst of a steady increase in the number of patients presenting to hospitals with acute coronary syndromes (ACS). This group includes patients with ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI) and unstable angina (chest pain without electrocardiographic changes or an enzyme rise). The optimal treatment of STEMI (currently thought to be primary percutaneous coronary intervention (PCI) or systemic thrombolysis) will not be discussed further here. For NSTEMI and unstable angina, the consensus of rapidly evolving guidelines is that management should be based upon a system of risk stratification, incorporating an assessment of chest pain, ECG changes and cardiac markers.1 For patients in the high risk group, recent trials show that an early invasive strategy (coronary angiography followed by revascularisation when appropriate) is superior to a conservative one, in terms of recurrent ischaemic episodes, if not lives saved.2–4 We are now left with the question of which mode of revascularisation should be selected for individual patients.

    NEW PCI VERSUS NEW CABG

    Conventional surgical revascularisation, as performed routinely, achieves a combined average risk of < 3% and the prospect of an excellent long term outcome.5 This operative risk may be further reduced, particularly in high risk patients, by avoiding cardiopulmonary bypass, using “off-pump” CABG (OPCABG),6,7 while total arterial revascularisation may further improve long term outcome.8 On the other hand, conventional stents have minimised the periprocedural risk of PCI to < 2%, while drug eluting stents have recently been shown to reduce restenosis rates to single figures in selected lesions.9,10

    TRIAL EVIDENCE

    What evidence is there to guide …