Percutaneous Coronary Intervention “Dominates” Coronary Artery Bypass Graft Surgery for High-Risk Patients

In this issue of Circulation , Stroupe and colleagues present a cost-effectiveness analysis of the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME) trial1 that challenges physicians, hospitals, and healthcare planners to address how to best evaluate emerging, evolving, and mature technologies for their safety, efficacy, and impact on the health of our society.Article p 1251 The AWESOME trial2 randomized patients with ischemic symptoms refractory to medical therapy who were at high risk for adverse events after either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) to receive one of these as the initial revascularization strategy. These patients, encountered with increasing frequency in clinical practice, need revascularization to treat significant ischemia, but the revascularization procedure itself carries significant risk for them. “First, do no harm” is particularly difficult to apply to these patients because both the disease and the therapy may cause harm. The risk and benefit of the 2 available revascularization modalities for these patients, PCI and CABG, are particularly difficult to balance, to explain to patients, and to select with assurance that the best choice is made for each patient.The randomized trial showed that mortality at 1 to 3 years was no different in the 2 study arms,2 but patients in the PCI strategy arm experienced unstable angina and repeat revascularization more frequently. Despite this difference in what might be a quality-of-life concern, health-related quality of life was no different in the 2 arms.3 Similarly, the Trial of Invasive Versus Medical Therapy in the Elderly (TIME), which showed in a high-risk …