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Bypass Or Stents With Coronary Artery Disease? Patient Perceptions Determine The Choice Of Revascularization
Jason J. Han, Akhil Rao, Max Shin, Mark R. Helmers, Amit Iyengar, Benjamin Smood, William L. Patrick, John J. Kelly, Peter Altschuler, Alan Herbst, Pavan Atluri.
Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
BACKGROUND: Coronary artery bypass grafting (CABG) is a class I indication for patients with triple vessel coronary artery disease due to its long-term survival benefit. This study evaluated patient preferences between undergoing CABG vs. percutaneous coronary intervention (PCI) when presented with various levels of difference in outcomes. METHODS: An 11-question survey was distributed to respondents on Amazon Mechanical Turk (Seattle, WI), a virtual crowdsourcing platform, from November 1st to November 20th of 2021. The survey presented respondents with an evidence-based choice between undergoing CABG and PCI based on SYNTAX trial outcomes. Ten-point Likert scale questions evaluated the salience and the degree of fear associated with a list of common operative complications and concerns. Minimal financial incentive ($0.05) was offered. Chi-squared/Fisher’s exact test or Mann-Whitney U-tests were utilized. RESULTS: In total, 500 individuals completed the survey with a median age of 34.7 ± 11.3. Of the group, 50% were male, 58% were Caucasian, 63% received college education. Presented with a choice between CABG and PCI, 45.6% preferred PCI at baseline unless CABG offered significant benefit and 12.3% stated they would unconditionally refuse CABG. Presented with the risk of mortality at 10-years based on the SYNTAX trial between CABG and PCI (20.6% vs. 27.7%), 35.7% of the respondents still preferred PCI. When asked to quantify the absolute risk reduction in mortality required to choose CABG, 19.1% desired at least 5%, 17.5% desired at least 10%, and 25.1% desired at least 25%. On a Likert scale out of ten, individuals rated avoiding a heart attack (7.83) and a re-operation (7.54) as their most important decision-making considerations. Least important considerations were avoiding an incision and opening of the chest (5.97) and inability to work or manage matters at home post-surgery (5.96).
CONCLUSIONS: Patient preferences appear to consider factors beyond survival benefit when considering CABG versus PCI. Understanding them is important to optimizing shared decision-making, and should inform physician-patient communication. Hybrid revascularization strategies may provide a novel balance between CABG and PCI that can optimally meet patient preferences. 
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