The MASS II Study

MASS II [i] is a small, single-center study designed to compare the long term effects of Medical Therapy (MT), Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Grafting (CABG) among patients with stable angina, multivessel CAD and preserved ventricular function. Patients selected were appropriate candidates for all 3 therapies.

In MASS II 611 patients were randomly assigned to CABG (n=203), PCI (n=205), or MT (n=203). The 10-year survival rates were 74.9% with CABG, 75.1% with PCI, and 69% with MT (P=0.089). The trial’s primary end point was a composite of total mortality, Q-wave MI, and refractory angina requiring revascularization. Secondary end points included angina status, death due to a cardiac cause, and stroke.

At 5-year follow-up no significant differences were found between MT and PCI in the primary end points. CABG was superior than MT and PCI, although the difference in mortality was not significant.

However, a significant 47% risk reduction for CABG was noted in the incidence of primary end points during 5 years of follow-up (P=0.001, 95% confidence interval [CI] 0.36 to 0.77).

Primary End points at 10 years

The 10-year rates of myocardial infarction were 10.3% with CABG, 13.3% with PCI, and 20.7% with MT (P=0.010). The 10-year rates of additional revascularizations were 7.4% with CABG, 41.9% with PCI, and 39.4% with MT (P=0.001). Relative to the composite end point, Cox regression analysis showed a higher incidence of primary events in MT than in CABG (hazard ratio 2.35, 95% confidence interval 1.78 to 3.11) and in PCI than in CABG (hazard ratio 1.85, 95% confidence interval 1.39 to 2.47). Furthermore, 10-year rates of freedom from angina were 64% with CABG, 59% with PCI, and 43% with MT (P=0.001).

At 10 years follow-up, the MASS II trial found a strong, independent, protective association between CABG and the composite primary end point compared with MT and PCI after adjustment for sex, smoking, total cholesterol, previous MI, hypertension, diabetes, and the number of diseased vessels. Additionally, MT patients had less relief from symptomatic angina than did patients who underwent CABG or PCI.

Figure 1. Probability of event-free survival (free of overall mortality, unstable angina that required revascularization, or Q-wave MI) among patients in the MT, CABG, and PCI treatment groups.

Figure 2. HRs measuring association between composite end point and treatment allocation: CABG vs PCI.

The lowest rate of repeat revascularization procedures (from the present study) was noted after CABG, whereas a substantial proportion of patients undergoing MT alone (39%) crossed over to revascularization, and 41.9% of PCI patients required repeat revascularization procedures.


The 10-year results of MASS-II indicate that revascularization with CABG, improves the outcomes of patients with multivessel disease in comparison to MT and PCI in important events such cardiac death and MI, as well as subsequent revascularization procedures.

[i] Ten-Year Follow-Up Survival of the Medicine, Angioplasty, or Surgery Study (MASS II). Whady Hueb,et al. Circulation 2010;122;949-957



Revascularization in Patients with Diabetes

The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) study enrolled 1,900 patients over a 5-year period from 2005 through 2010.

Contemporary PCI and CABG techniques and currently recommended ancillary medical therapies were examined to determine whether CABG or PCI with drug-eluting stents are the superior approach to revascularization in patients with diabetes and multivessel coronary artery disease.

The FAME 1&2 Trials

Posted on March 31, 2013 - 4:42pm

In 1995 Topol[1] first described what vascular surgeons have known for many years:

The pressure drop in a fluid flowing through a long cylindrical pipe such as a stenotic artery becomes functionally significant when the obstruction exceeds 70%, first described in the Poiseuille law in 1846[2].

As was stated in Topol's paper: “Accordingly, before the residual stenosis in an infarct vessel is addressed, there should be demonstration of either spontaneous or provocable signs of ischemia… clinicians and investigators rely excessively on angiography for clinical decision-making… Procedures should not be performed solely to improve the luminal appearance—so-called coronary “cosmetology".

This principle was tested with the PCI Fractional Flow Reserve FAME 1[3]&2[4] trials:

SYNTAX Trial after Five Years: Final Results

Posted on November 13, 2012 - 6:03pm

In the SYNTAX trial 1800 patients with previously untreated left-main or three-vessel disease were randomized to CABG or PCI.

As expected, differences in long-term outcomes of Coronary Artery Bypass Grafting vs. PCI, already present after year one, have continued to become more obvious during the next four years:

SYNTAX five-year results for patients with three-vessel disease:

PCI vs. CABG outcomes in Washinton State

In a large comparative study, interventions for CAD were compared. From 1999-2007 more than 150000 interventions were performed in Washington State. During that period, the volume of PCI procedures increased by 71%, while simultaneously, CABG diminished by almost 40%. In final analysis, PCI was almost five times more likely to happen than CABG.

SYNTAX Trial: Four-year follow-up analysis

Posted on November 5, 2012 - 10:22am

SYNTAX was an 1800-patient trial randomizing patients with left main coronary disease and/or three-vessel disease to either CABG or PCI using the Taxus drug-eluting stent (DES).


In patients with severe, multi-vessel coronary disease, coronary artery bypass grafting (CABG) continues as the standard of care of revascularization. Death and MI rates did become significantly greater in the PCI group after four years:

Long Term Survival of Adenocarcinoma of the Esophagus

Posted on December 5, 2010 - 7:52pm

Carcinoma of the esophagus is a relatively rare but very lethal disease. 50% of all patients diagnosed will have adeno carcinoma, which has been associated with a very poor long term survival.

PCI & CABG for Diabetics with 3VD

Posted on November 5, 2010 - 4:23pm

A subset of patients with diabetes and 3VD was examined in a 2nd paper in 2010.

The MASS II Study

MASS II [i] is a small, single-center study designed to compare the long term effects of Medical Therapy (MT), Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Grafting (CABG) among patients with stable angina, multivessel CAD and preserved ventricular function. Patients selected were appropriate candidates for all 3 therapies.

The Courage Trial - Optimal Medical Therapy with or without PCI for Stable Coronary Disease

Optimal Medical Therapy with or without PCI for Stable Coronary Disease

William E. Boden, M.D.,and others, NEJM april 12, 2007.

This study was performed to evaluate and compare optimal medical therapy with percutaneous coronary intervention (PCI).

PCI vs. CABG – A Current Perspective

In all likelihood this article has only been read by cardiac surgeons. It provides "new" (actually old) information about what constitutes current and optimal therapy for CAD, and especially what long term outcomes can be expected. For this reason the article was printed in its entirety:

Percutaneous Coronary Intervention (PCI) – Risks & Benefits

Posted on December 30, 2009 - 3:55pm

Comments: If there is any area where primary PCI is of particular value, it is in STEMI. No other procedure promises better and/or quicker myocardial reperfusion, and this discussion illustrates this very well {From: Primary PCI for Myocardial Infarction with ST-Segment Elevation by Ellen C. Keeley, M.D., and L. David Hillis, M.D. (NEJM: Volume 356:47-54 January 4, 2007)}:

A 58-year-old man has chest pain at 9:30 a.m.; 3 hours later, he calls for an ambulance.

Survival of patients with diabetes and multivessel coronary artery disease

Posted on April 1, 2010 - 9:17pm

… Published the results of survival of patients with diabetes and MVD after surgical or percutaneous coronary revascularization. Their results showed that in 2766 risk matched diabetics PCI increased five-year mortality by 1.5–3.9 times...

In 2,766 patients with diabetes undergoing their first coronary revascularization procedure, improved survival with CABG was the initial revascularization demonstrated. The analysis supported that bypass surgery is preferable to coronary angioplasty for the revascularization of patients with diabetes with both 2VD- and 3VD:

Physical Activity and Weight Gain Prevention

In a paper, published in JAMA in 2010, the association of different amounts of physical activity with long-term weight changes among women consuming a usual diet was examined.

The BARI 2D Trial

Posted on April 30, 2010 - 5:50pm

The BARI 2D Study Group. A randomized trial of therapies for type 2 diabetes and coronary artery disease.

In this study, the authors report the findings of the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, involving 2368 patients with both diabetes and coronary disease.