Management of chronic total coronary occlusion in stable ischemic heart disease by percutaneous coronary intervention versus coronary artery bypass grafting versus medical therapy

Coronary chronic total occlusions (CTOs) are found in approximately 20% of angiograms. We sought to assess the variation in the management of CTO patients and to contrast clinical outcomes of CTO versus non-CTO lesions. We conducted a population-based cohort study and included all patients with stable angina who underwent cardiac catheterization from October 1, 2012, to June 30, 2013 in Ontario, Canada. The primary outcome was a composite of mortality and hospitalization for myocardial infarction. A total of 7,864 patients were included, of whom 2,279 (29%) had a CTO. There were substantial differences in revascularization rates for CTO patients across hospitals in Ontario (44.9%-94.1%). Revascularization was associated with improved outcomes in the overall cohort. Although the advantage of CABG over medical therapy was consistent in both CTO and non-CTO patients, the benefit of PCI was limited to non-CTO patients (HR 0.56, 95% CI 0.40-0.78), with no difference in CTO patients. The CTO lesion however was revascularized in few of the PCI cases (41.1%), with PCI limited to the non-CTO lesion in most patients.