Dr. Jacobs described general guidelines for deciding appropriate treatment for patients with coronary artery disease. These indicate percutaneous coronary intervention is appropriate for low to moderate risk patients, patients without left ventricular dysfunction and inoperable patients. Coronary artery bypass surgery is the procedure of choice for diabetics and some high risk patients and patients with multi-vessel disease.

Dr. Jacobs described the current procedures used to treat of coronary artery disease. These are percutaneous coronary intervention, coronary stents and coronary artery bypass surgery. She asked the question, "what is the appropriate procedure to use in patients with multi-vessel disease?"

To answer this question, Dr. Jacobs reviewed the data provided by many randomized clinical trials conducted between 1980 and the present. These data indicate that coronary artery bypass surgery resulted in a significantly lower incidence of myocardial infarctions, emergency bypass procedures and repeat revascularizations. Percutaneous coronary intervention and coronary stents were associated with higher incidences of repeat revascularizations, and their major problem was restenosis that requires repeat revascularizations.

Dr. Jacobs provided the following guidelines for determining which procedure to use. She noted percutaneous coronary intervention is an excellent technique for patients with a high risk of operative mortality. This procedure is better for low to moderate risk patients with one vessel disease without left ventricular dysfunction. In high risk and inoperable patients, percutaneous coronary intervention may provide palliation.

Coronary artery bypass surgery is most beneficial for patients with one vessel and proximal left ventricular dysfunction as well as patients with multi-vessel disease with and without proximal left ventricular dysfunction. It is also used for high risk patients, such as diabetics. If patients are candidates for both procedures, the decision may be made after considering patient preference, quality of life and cost. The stent procedure (including repeat revascularizations and medications) costs less than coronary artery bypass surgery.

Dr. Jacobs concluded by reiterating that restenosis is the current problem with stents. New stents are being developed with little to no occurrence of restenosis. If these coated stents decrease revascularization procedures, the guidelines for patients who are eligible for percutaneous intervention may change and it may be easy to decide when multivessel stenting is preferable to coronary bypass surgery.