martedì 10 aprile 2007

By pass o stent ?




Aziz O et al. Meta-analysis of minimally invasive internal thoracic artery
bypass versus percutaneous revascularisation for isolated lesions of the
left anterior descending artery. BMJ 2007 Mar 24; 334:617.


Continua l'infinita controversia se sia più efficace il by pass aorto coronarico o lo stent nei vari sottogruppi di pazienti che necessitano di rivascolarizzazione.
Una metanalisi pubblicata nell'ultimo numero del BMJ  ha studiato gli effetti a lungo termine dell'angioplastica con stent rispetto al by pass minimamente invasivo sulla discendente anteriore. Lo stent è risultato associato ad una maggiore incidenza di angina e di successivi eventi cerebrovascolari. La mortalità tra i due gruppi era simile. Una valutazione costo beneficio mostra valori simili a due anni ma  a 5 anni il by pass sembrerebbe più efficace.
Va detto che questa metanalisi non ha preso in considerazione studi con stent medicati.
Allego un editoriale del Journal Watch.

Stenting vs. Coronary Bypass Surgery for CAD
Analyses indicate that CABG is more cost-effective than stenting.

Controversy continues regarding the preferred treatment for many subgroups
of patients who require revascularization for coronary artery disease. New
analyses suggest that the value of stenting may be less than that of
coronary artery bypass grafting in several settings.

A meta-analysis compared stenting with minimally invasive CABG of the left
anterior descending artery. Stenting was associated with a higher rate of
recurrent angina (odds ratio, 2.62), a higher incidence of major cerebral
and coronary events (OR, 2.86), and greater need for repeat coronary
revascularization (OR, 4.63). Mortality was similar with the two
approaches. A cost-effectiveness analysis using the same data showed
stenting to be more cost-effective in the first 2 years, but by 5 years
CABG was more cost-effective.

Another cost-effectiveness analysis was based on a prospectively observed
group of 1720 patients with CAD who were deemed clinically appropriate to
receive CABG only, stenting, or both procedures. The patients actually
underwent any of three approaches: CABG, stenting, or medical management.
CABG was significantly more cost-effective than stenting in patients deemed
appropriate for that procedure and in those deemed appropriate for both
procedures. In none of the three groups was stenting most cost-effective.

Comment: These studies, using different approaches and different groups of
patients, find that CABG is more likely to be cost-effective than stenting,
at least as likely to reduce mortality, and less likely to lead to
additional complications. These data did not include patients receiving
drug-eluting stents. In an accompanying editorial, a cardiac surgeon calls
for multidisciplinary teams that include noninterventional cardiologists
and cardiac surgeons to be available to advise patients considering
revascularization.

-- Keith I. Marton, MD

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