Indications for percutaneous and surgical revascularisation: how far does the evidence base guide us?

T he treatment of patients with coronary artery disease continues to evolve, including those presenting with stable angina pectoris as well as those presenting with acute coronary syndromes. Pharmacological treatments which have changed practice in recent years include statins, angiotensin converting enzyme inhibitors, clopidogrel, and glycoprotein IIb/IIIa inhibitors. There have been major changes in percutaneous coronary intervention (PCI), particularly with the introduction of coronary artery stents. More recently, the appearance of drug eluting stents which may modulate smooth muscle cell proliferation has generated interest, as well as the use of adjunctive pharmacological treatment with stenting. In terms of surgical revascularisation, practice continues to evolve. There has been an expansion in the use of arterial conduits in order to improve long term graft patency. Less invasive approaches for surgery have been developed, as well as the use of "off-pump" coronary artery bypass graft surgery (CABG), in an attempt to reduce the risks associated with surgical revascularisation.