Drug-eluting stents may be a safe and effective alternative to bypass surgery in certain subsets of patients with complex coronary artery disease.

Associate Professor Dr Yap Yee Guan
BMedSci(Hons)(Nottm), MBBS(Nottm), MD(Lond), CCT(UK)(Cardiology & Int. Medicine), European Cardiologist(Europe), AM, FAMS, FRCP(Glasg), FRCP(Edin), FRCP(Lond), FESC(Europe), FSCAI(USA), FAHA(USA), FACC(USA)
Consultant Interventional Cardiologist Prince Court Medical Centre, Kuala Lumpur


Coronary angioplasty and stenting has been well-established as an effective way to treat coronary patients with single or double vessel and relieve them from symptomatic angina chest pain. Traditionally, patients with triple vessels coronary artery disease have been treated with coronary bypass surgery. Recently, coronary stenting with drug-eluting stents has been found to be a safe and effective alternative to bypass surgery for patients with triple vessels or left main stem coronary artery disease.

In a landmark study on 1800 patients presented recently in the European Society of Cardiology meeting and the American Angioplasty meeting (named Transcatheter Cardiovascular Therapeutics), the SYNTAX trial showed that in patients with triple vessel or left main stem coronary artery disease, coronary angioplasty with drug-eluting stents has 7.6% combined risks of death, stroke and heart attack, similar to that with coronary bypass operation at 7.5% at 12-month of follow-up. However, patients who underwent coronary stenting had a higher risk of repeat angioplasty subsequently at 13.7% than bypass surgery at 5.9%. On the other hand, patients who had bypass surgery had a higher risk of stroke at 2.2% versus 0.6% for coronary stenting during a period of 1 year after their procedures. Generally speaking, patients with left main stem coronary narrowing only, the risk of stenting (combined risks of death, stroke, heart attack and repeat revascularization) with drug-eluting stents is similar to surgery whereas in patients with tripple vessel disease, the combined risks of stenting is higher than bypass surgery, mainly driven by the need for repeat revascularistion.

The results from this trial showed that the techniques and technologies of both coronary stenting and bypass surgery have improved but the study was carried out in experienced centres across Europe and United States. For the first time, in coronary patients with the most complex disease who were traditionally treated with bypass surgery, this study showed that there were comparable overall safety in the combined outcomes of death, stroke or heart attack after procedures with both stenting using drug-eluting stents and bypass surgery. There was a significantly higher rate of repeat revascularization procedure in stenting patient but a higher rate of stroke in the bypass patients. It is important that patients with complex coronary artery disease discuss their conditions and options of treatment carefully with an experienced team of skillful interventional cardiologist and cardiac surgeon who together, will provide the patients with a balanced view of the state-of-the-art treatment in complex coronary artery disease and tailor the treatment individually.