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March 5, 1997

Five-Year Clinical and Functional Outcome Comparing Bypass Surgery and Angioplasty in Patients With Multivessel Coronary DiseaseA Multicenter Randomized Trial

JAMA. 1997;277(9):715-721. doi:10.1001/jama.1997.03540330037032

Objective.  —To compare clinical and functional status in patients who had similar 5-year survival after coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA).

Design.  —Randomized trial of 1829 patients followed for an average 5.4 years.

Participants.  —Patients with multivessel coronary artery disease suitable for both CABG and PTCA and not previously revascularized.

Intervention.  —Coronary artery bypass grafting or PTCA within 2 weeks after randomization.

Outcome Measures.  —Symptoms, exercise test results, medication use, and quality-of-life measures collected at 4 to 14 weeks, and at 1, 3, and 5 years after randomization.

Analysis.  —Intention to treat.

Results.  —Differences in angina-free rates between patients assigned to PTCA and CABG decreased from 73% vs 95% at 4 to 14 weeks (P<.001) to 79% vs 85% at 5 years (P=.007). Similar patterns were observed for exercise-induced angina and ischemia, except 5-year differences were not significant. At follow-up of 1 year and later, quality of life, return to work, modification of smoking and exercise behaviors, and cholesterol levels were similar for the 2 treatments. Compared with patients assigned to CABG, use of anti-ischemic medication was higher in patients assigned to PTCA, while smaller differences were observed for other medications. Among patients angina-free at 5 years, 52% of patients who had PTCA required revascularization after the initial procedure vs 6% of patients who had CABG.

Conclusions.  —The narrowing of treatment differences in angina and exerciseinduced ischemia rates can be attributed to a return of symptoms among patients assigned to CABG and incremental surgical procedures among patients assigned to PTCA. Patients assigned to PTCA apparently were able to tolerate higher rates of residual ischemia as evidenced by comparable quality of life and 5-year survival.