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CLINICAL STUDY

Percutaneous coronary intervention versus repeat bypass surgery for patients with medically refractory myocardial ischemia

AWESOME randomized trial and registry experience with post-CABG patients

Douglass A. Morrison, MD, FACC^*,*, Gulshan Sethi, MD, FACC^*, Jerome Sacks, PhD, William G. Henderson, PhD, Frederick Grover, MD, FACC, Steven Sedlis, MD, FACC, Rick Esposito, MD Investigators of the Department of Veterans Affairs Cooperative Study #385, the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME)^*

^* Tucson VA Medical Center and the University of Arizona, Tucson, Arizona, USA
Hines VA Cooperative Studies, Hines, Illinois, USA
Denver VA Medical Center and the University of Colorado, Denver, Colorado, USA
New York VA Medical Center and the New York Univerity, New York, New York, USA

Manuscript received August 8, 2002; accepted August 26, 2002.

^* Reprint requests and correspondence: Dr. Douglass A. Morrison, Director, Cardiac Catheterization Laboratory, Southern Arizona Veterans Affairs Healthcare System, Professor of Medicine and Radiology, University of Arizona, (111 C) SAVAHCS, 3601 S. Sixth Ave., Tucson, Arizona 85723, USA.
douglass.morrison{at}med.va.gov

OBJECTIVES: This report compares long-term percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) survival among post-CABG patients included in the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME) randomized trial and prospective registry.

BACKGROUND: Repeat CABG surgery is associated with a higher risk of mortality than first-time CABG. The AWESOME is the first randomized trial comparing CABG with PCI to include post-CABG patients.

METHODS: Over a five-year period (1995 to 2000), patients at 16 hospitals were screened to identify a cohort of 2,431 individuals who had medically refractory myocardial ischemia and at least one of five high-risk factors. There were 454 patients in the randomized trial, of whom 142 had prior CABG. In the physician-directed registry of 1,650 patients, 719 had prior CABG. Of the 327 patient-choice registry patients, 119 had at least one prior CABG. The CABG and PCI survivals for the three groups were compared using Kaplan-Meier curves and log-rank tests.

RESULTS: The CABG and PCI three-year survival rates were 73% and 76% respectively for the 142 randomized patients (75 and 67 patients) (log-rank = NS). In the physician-directed registry, 155 patients were assigned to reoperation and 357 to PCI (207 received medical therapy); 36-month survivals were 71% and 77% respectively (log-rank = NS). In the patient-choice registry, 32 patients chose reoperation and 74 chose PCI (13 received medical therapy); 36-month survivals were 65% and 86% respectively (log-rank test p = 0.01).

CONCLUSION: Percutaneous coronary intervention is preferable to CABG for many post-CABG patients.

Abbreviations and Acronyms   AWESOME   Angina With Extremely Serious Operative Mortality Evaluation   CABG   coronary artery bypass graft   PCI   percutaneous coronary intervention

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