Coronary artery bypass graft and percutaneous transluminal coronary angioplasty

Purpose of Assessment

The report consists of two parts: a literature review and panel ratings of appropriateness and necessity of Coronary Artery Bypass Graft (CABG) and Percutaneous Transluminal Coronary Angioplasty (PTCA). The results are used for auditing medical practice to determine the appropriateness and necessity of CABG and PTCA. During 1994, medical and quality of life information was prospectively collected on all patients referred for coronary angiography with suspected coronary artery disease in Sweden. The panels ratings of appropriateness and necessity of these procedures will be used to determine to what extent there is an under-use and over-use of these procedures.

Methods

Systematic Review, Expert panel

Primary Data Collection

The present literature review was based on a search of the MEDLINE database. Articles published between July 1990 (CABG) or October 1990 (PTCA) and March 1993 were included. Additional references were retrieved from reference lists in the MEDLINE articles. Panel meetings were held in November 1993 (Appropriateness ratings) and December 1993 (Necessity ratings).

Basis for selection of data; type of study included

Of 1275 research articles reviewed only 90 (7%) were randomized, controlled trials: 65 related to CABG and 25 to PTCA: After review, 283 articles were selected, 266 from the MEDLINE search and 17 from reference lists in the articles reviewed. These articles form the basis for this review. Priority order for selection of articles was research that used randomized, controlled trials, had a prospective design, included a large number of cases, or addressed new issues.

Review process for the publication

Internal review by project steering committee, project reference group, SBU Board and SBU Expert Group. Additional external review by experts in the field.

Content of Report

The report includes:

(a) a review of the literature on the efficacy and risks of CABG and PTCA published from 1990 to March 1993

(b) a description of methods for rating a comprehensive set of indications for performing CABG and PTCA, and

(c) a presentation of how a panel of Swedish experts rated the appropriateness and necessity of indications for CABG and PTCA.

The panel judged 1,040 indications for PTCA and 1,098 indications for CABG, grouped in 8 chapters according to major medical problem. For each indication in each chapter, patients were divided into two categories: (a) a low to moderate surgical risk category, or (b) a high surgical category. Each of these two categories were rated three times, ie, PTCA compared to medical therapy, CABG compared to medical therapy, and preference for PTCA or CABG.

Recommendations/Conclusions

The chapters on chronic stable angina and on post myocardial infarction comprise the most common types of patients presented for intervention, and it should be noted that a large number of possible indications were judged as uncertain. This may reflect the construction of the indication matrix, which may have been more detailed than the panellists were used to. Partly it reflects real uncertainty in a situation which requires the interventionist to exactly describe what information is needed for a decision to intervene or not.

Impact of Assessment

The discussion within professional groups stimulated by this report will certainly influence the way patients are cared for. The planned continuation of the SBU project is also important in this respect.