Coronary angioplasty versus coronary artery bypass surgery: the Randomised Intervention Treatment of Angina (RITA) trial

Abstract

The Randomised Intervention Treatment of Angina (RITA) trial is comparing the long-term effects of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG) in patients with one, two, or three diseased coronary arteries in whom equivalent revascularisation was deemed achievable by either procedure. This first report is for a mean 2·5 years' follow-up on the 1011 patients randomised. 59% had grade 3 or 4 angina, 59% had experienced angina at rest, and 55% had two or more diseased coronary arteries. The intended procedure was done in 98% of patients. In 97% of CABG patients all intended vessels were grafted. Dilatation of all treatment vessels was attempted in 87% of PTCA patients with an angiographic success rate per vessel of 87% (90% excluding occluded vessels). There have been 34 deaths (18 CABG, 16 PTCA) and the pre-defined combined primary event of death or definite myocardial infarction shows no evidence of a treatment difference (43 CABG, 50 PTCA; relative risk 0·88 [95% confidence interval 0·59-1·29]). 4% of PTCA patients required emergency CABG before discharge and a further 15% had CABG during follow-up. Within 2 years of randomisation 38% and 11% of the PTCA and CABG groups, respectively, required revascularisation procedure(s) or had a primary event (p <0·001) and repeat coronary arteriography during follow-up was four times more common in PTCA than in CABG patients (31% vs 7%, p<0·001). The prevalence of angina during follow-up was higher in the PTCA group (eg, 32% vs 11% at 6 months) but this difference became less marked after 2 years (31% vs 22%). Anti-anginal drugs were prescribed more frequently for PTCA patients. At 1 month CABG patients were less physically active, with greater coronary related unemployment and lower mean exercise times than the PTCA patients. Thereafter employment status, breathlessness, and physical activity improved, with no significant differences between the two treatment groups. At 1 year mean exercise times had increased by 3 min for both groups. These interim findings indicate that recovery after CABG, the more invasive procedure, takes longer than after PTCA. However, CABG leads to less risk of angina and fewer additional diagnostic and therapeutic interventions in the first 2 years than PTCA. So far, there is no significant difference in risk of death or myocardial infarction, and follow-up continues to at least five years.