Coronary angioplasty versus bypass grafting: Cost-Benefit considerations

Both PTCA and CABG are effective strategies for coronary revascularization. The initial cost of PTCA is 60% to 75% less than that of CABG. PTCA patients, however, often require repeat procedures secondary to restenosis and incomplete revascularization. Despite this, the cost of PTCA is still approximately half that of CABG at 1 year but approaches that of CABG at 3 years. The BARI SEQOL trial will be available in 1996 and will analyze cost differences as well as quality of life for PTCA versus CABG up to 5 years after revascularization. Patients with single-vessel disease can be treated effectively with PTCA or medications. Although PTCA is more expensive, patients have less angina and better exercise tolerance. Many patients with single-vessel disease are now treated with PTCA, who in the past would have been treated medically. Undoubtedly, this change has added to the increasing cost of health care. Although certain patient groups, such as those with three-vessel disease and low ejection fraction and left-main disease, have a significant mortality advantage when revascularized surgically, many patients with symptomatic two-vessel and three-vessel disease can be treated either with CABG or PTCA with no difference in mortality and MI. To reach this equivalent outcome, however, PTCA patients require more interventional procedures. As a result, at 3 years, there is no cost savings with PTCA. Physicians in the United States have been able to choose the mode of revascularization for patients based on clinical judgment and preference, which has been financed by third-party payers. Given the escalating costs of health care in a country with limited resources, physicians failing to consider costs and benefits may find their choices limited secondary to lack of funding and restrictive policies. Future treatment of CAD will most likely be influenced by aggressive lipid-lowering therapy to prevent secondary cardiac events and possibly by gene therapy to prevent restenosis.