Review of invasive treatments of coronary artery disease.

Coronary artery disease is a difficult clinical entity to manage, and all forms of current therapy are palliative in nature. Results from the large randomized studies have clearly demonstrated the superiority of surgical versus medical therapy in subsets of patients previously described herein. As patients with severely compromised ventricles are demonstrated to fare better with bypass procedures, the number of patients that should be operated upon continues to grow. With refinements in operative and perioperative care and increased use of the internal mammary artery as the bypass conduit, it is inevitable that more subgroups will be determined to be best managed by surgical revascularization. For the present time, medical treatment is preferred for the vast majority of patients who were shown by randomized trials not to benefit significantly from surgical intervention. However, caution must be used in excluding patients based on trial results that used surgical techniques and conduits that are ten years old. The role of angioplasty in the invasive treatment of ischemic cardiac disease is still in evolution. Although not yet proved by vigorous trials, it is a procedure that most likely will continue to be used in many clinical applications. The high rate of restenosis after angioplasty, which is a formidable problem, may be a factor that will limit the application of angioplasty to patients with acute myocardial infarction or to those who do not desire surgical intervention. The answers to these and other complex problems of patient management must await well-designed prospective trials comparing angioplastic with surgical revascularization. Clinical use of some of the experimental procedures mentioned is certain; the efficacy and role of these procedures in the treatment of ischemic cardiac disease must also be defined with future studies.