ASCERT: The American College of Cardiology Foundation–The Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies

Coronary artery disease (CAD) is a major cause of morbidity and mortality worldwide. Despite intensive appraisal, there remain questions regarding the comparative effectiveness of the two forms of coronary revascularization therapy, percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery. Clinical experience and randomized clinical trials have shown that some patients are better served with percutaneous coronary intervention (PCI) while others experience more benefit with coronary artery bypass surgery (CABG) 1, 2. However, there remains a large population in which the optimal treatment is not well-defined. All of the existing randomized trials over the past 15 years comparing PCI to CABG in multivessel CAD have concluded that, overall, CABG is associated with fewer long-term major clinical events. However, the observed improvement in survival is limited to patients with diabetes, and the benefit of fewer repeat procedures is most prominent in those with very extensive CAD. The major advantages of CABG are its ability to achieve complete revascularization, particularly in the setting of chronic total occlusion, and the superior durability of its results, with less residual angina. Its drawbacks include a relatively long recuperation period and a significant incidence of morbidity, including more cerebrovascular events. In contrast, the major advantages of contemporary PCI are its non-invasive nature, the speed of achieving normal or near normal perfusion in acute coronary syndromes, and relatively minimal morbidity. Additionally, PCI is also effective in diminishing anginal symptoms, particularly in high risk patients. The opportunity for a less invasive approach in multivessel CAD appears to have become more of a reality since the introduction of drug eluting stents, which has shown improved survival in non-randomized trials and reduced repeat revascularization compared to older percutaneous methods. More residual angina and more repeat procedures are the critical shortcomings of PCI 3-5. The National Cardiovascular Disease Registry working groups of the American College of Cardiology (ACC) in collaboration with the ACC Interventional Scientific Council and the Society of Thoracic Surgery (STS) effectively collaborated in developing a unique grant proposal that was recently awarded a Grand Opportunity grant by the NHLBI to study the comparative effectiveness of PCI and CABG for the treatment of stable coronary artery disease. This study will compare catheter-based and surgery-based procedures using the existing ACC and STS databases, as well as the Centers for Medicare and Medicaid Services (CMS) 100% denominator file data. This study will attempt to bring clarity to the therapeutic decisions required for patients with multivessel CAD. The specific patient characteristics that favor one mode of treatment over the other will be sought and details impacting the selection of patients clearly described. The findings of this study will help physicians make better decisions and improve healthcare for patients with CAD.