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J Thorac Cardiovasc Surg 2006;132:1001-1009
© 2006 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Treatment decisions in stable coronary artery disease: Insights from the Euro Heart Survey on Coronary Revascularization

Arno Breeman, MD, PhDa, Marjo Hordijk-Trion, MDb, Mattie Lenzen, MScb, Sanne Hoeks, MScb, Jan Paul Ottervanger, MD, PhDa, Michel E. Bertrand, MD, PhDc, Udo Sechtem, MD, PhDd, Remigijus Zaliunas, MD, PhDe, Victor Legrand, MD, PhDf, Menko-Jan de Boer, MD, PhDa, Elisabeth Stahle, MD, PhDg, Nestor Mercado, MD, PhDb, William Wijns, MD, PhDh, Eric Boersma, PhDb,* Euro Heart Survey on Coronary Revascularization

a Isala Klinieken, Zwolle, The Netherlands
b Erasmus MC, Rotterdam, The Netherlands
c Lille Heart Institute, University of Lille, Lille, France
d Robert Bosch Hospital, Stuttgart, Germany
e Kaunus Medical University Hospital, Kaunus, Lithuania
f CHU Sart Tilman, Liege, Belgium
g Department of Cardiothoracic Surgery, University Hospital, Uppsala, Sweden
h Cardiovascular Center, Aalst, Belgium.

Received for publication January 20, 2006; revisions received May 18, 2006; accepted for publication May 24, 2006.

* Address for reprints: Eric Boersma, PhD, FESC, Clinical Epidemiology Unit, Thoraxcenter Cardiology, Room Ba563, Erasmus MC, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands. (Email: h.boersma{at}erasmusmc.nl).

OBJECTIVE: We sought to assess determinants of clinical decision making in patients with stable coronary artery disease.

METHODS: The 2936 patients with stable angina pectoris who enrolled in the Euro Heart Survey on Coronary Revascularization were the subject of this analysis. After the diagnosis has been confirmed, physicians decided on treatment: medical management or revascularization therapy by means of percutaneous coronary intervention or coronary bypass surgery. We applied logistic regression analyses to evaluate the relation between baseline characteristics and treatment decision: medical treatment versus percutaneous coronary intervention, medical treatment versus coronary bypass surgery, and percutaneous coronary intervention versus coronary bypass surgery.

RESULTS: The median age was 64 years, 77% were men, and 20% had diabetes. Medical therapy was intended in 690 (24%) patients, percutaneous coronary intervention in 1503 (51%) patients, and coronary bypass surgery in the remaining 743 (25%) patients, respectively. Revascularization was generally preferred in patients with more severe anginal complaints, an intermediate-to-large area of myocardium at risk, and preserved left ventricular function who had not undergone prior coronary revascularization, provided lesions were suitable for treatment. Coronary bypass surgery was preferred over percutaneous coronary intervention in multivessel or left main disease, as well as in those with concomitant valvular heart disease, provided a sufficient number of lesions were suitable for coronary bypass surgery. In those with previous coronary bypass surgeries, more often percutaneous coronary intervention was preferred than redo coronary bypass surgery. Diabetes was not associated with more frequent preference for coronary bypass surgery.

CONCLUSIONS: In the hospitals that participated in the Euro Heart Survey on Coronary Revascularization, treatment decisions in stable coronary artery disease were largely in agreement with professional guidelines and determined by multiple factors. Most important deviations between guideline recommendations and clinical practice were seen in patients with extensive coronary disease, impaired left ventricular function, and diabetes.

Abbreviations and Acronyms CABG = coronary artery bypass grafting; EHS = Euro Heart Survey; EHS-CR = Euro Heart Survey on Coronary Revascularization; LAD = left anterior descending artery; PCI = percutaneous coronary intervention




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