In the Journals

CABG confers better mortality rate than PCI in multivessel disease

Deepak L. Bhatt, MD, MPH
Deepak L. Bhatt

Among patients with multivessel disease, CABG mortality rates were lower vs. those who had PCI with stenting, according to a meta-analysis.

The difference was most pronounced in patients with diabetes and high coronary complexity, and was not significant in patients with left main CAD, researchers reported in The Lancet.

Stuart J. Head, MD, from the department of cardiothoracic surgery, Erasmus University Medical Center, Rotterdam, the Netherlands, and colleagues analyzed 11,518 patients with multivessel disease or left main CAD from 11 randomized trials who were assigned to undergo CABG or PCI with stenting. Mean follow-up was 3.8 years. Mean SYNTAX score was 26, with 22.1% of patients having a score of 33 or higher.

Mortality results

At 5 years, all-cause mortality in the overall cohort was 11.2% in the PCI group and 9.2% in the CABG group (HR = 1.2; 95% CI, 1.06-1.37), according to the researchers.

Among patients with multivessel disease, 5-year all-cause mortality was 11.5% in the PCI group and 8.9% in the CABG group (HR = 1.28; 95% CI, 1.09-1.49), and the difference was more pronounced in those with diabetes (15.5% vs. 10%; HR = 1.48; 95% CI, 1.19-1.84), but not significant in those without diabetes (PCI, 8.7%; CABG, 8%; HR = 1.08; 95% CI, 0.86-1.36).

In the multivessel disease cohort, the higher the SYNTAX score, the greater the mortality benefit from CABG, as the mortality difference was significant in those with a SYNTAX score of 33 or higher but not in those with a score of 32 or lower, Head and colleagues wrote.

In patients with left main disease, 5-year all-cause mortality was similar in those who underwent PCI (10.7%) and those who underwent CABG (10.5%; HR = 1.07; 95% CI, 0.87-1.33), and the difference was not affected by diabetes status or SYNTAX score, according to the researchers.

“Consideration of coronary lesion complexity is important when choosing the appropriate revascularization strategy,” Head and colleagues wrote. “Longer follow-up is needed to better define mortality differences between the interventions.”

Current standard

In a related editorial, Cardiology Today’s Intervention Chief Medical Editor Deepak L. Bhatt, MD, MPH, executive director of interventional cardiovascular programs at Brigham and Women’s Heart & Vascular Center and professor of medicine at Harvard Medical School, wrote: “These results help affirm CABG as the treatment of choice when revascularization in patients with complex multivessel disease and diabetes is deemed to be necessary, assuming the patient is an appropriate surgical candidate. ... Although the revascularization gap in favor of CABG over PCI has narrowed somewhat with newer-generation drug-eluting stents, the mortality gap has not.”

He concluded: “In general, with increasing angiographic lesion complexity, the scales tip toward CABG. Advances in medical therapy and PCI might change this calculus, but in the absence of long-term data from randomized clinical trials, the results of this pooled analysis should set the current standard.” – by Erik Swain

Disclosures: Head reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Bhatt reports he has financial ties with numerous pharmaceutical and device companies.

Deepak L. Bhatt, MD, MPH
Deepak L. Bhatt

Among patients with multivessel disease, CABG mortality rates were lower vs. those who had PCI with stenting, according to a meta-analysis.

The difference was most pronounced in patients with diabetes and high coronary complexity, and was not significant in patients with left main CAD, researchers reported in The Lancet.

Stuart J. Head, MD, from the department of cardiothoracic surgery, Erasmus University Medical Center, Rotterdam, the Netherlands, and colleagues analyzed 11,518 patients with multivessel disease or left main CAD from 11 randomized trials who were assigned to undergo CABG or PCI with stenting. Mean follow-up was 3.8 years. Mean SYNTAX score was 26, with 22.1% of patients having a score of 33 or higher.

Mortality results

At 5 years, all-cause mortality in the overall cohort was 11.2% in the PCI group and 9.2% in the CABG group (HR = 1.2; 95% CI, 1.06-1.37), according to the researchers.

Among patients with multivessel disease, 5-year all-cause mortality was 11.5% in the PCI group and 8.9% in the CABG group (HR = 1.28; 95% CI, 1.09-1.49), and the difference was more pronounced in those with diabetes (15.5% vs. 10%; HR = 1.48; 95% CI, 1.19-1.84), but not significant in those without diabetes (PCI, 8.7%; CABG, 8%; HR = 1.08; 95% CI, 0.86-1.36).

In the multivessel disease cohort, the higher the SYNTAX score, the greater the mortality benefit from CABG, as the mortality difference was significant in those with a SYNTAX score of 33 or higher but not in those with a score of 32 or lower, Head and colleagues wrote.

In patients with left main disease, 5-year all-cause mortality was similar in those who underwent PCI (10.7%) and those who underwent CABG (10.5%; HR = 1.07; 95% CI, 0.87-1.33), and the difference was not affected by diabetes status or SYNTAX score, according to the researchers.

“Consideration of coronary lesion complexity is important when choosing the appropriate revascularization strategy,” Head and colleagues wrote. “Longer follow-up is needed to better define mortality differences between the interventions.”

Current standard

In a related editorial, Cardiology Today’s Intervention Chief Medical Editor Deepak L. Bhatt, MD, MPH, executive director of interventional cardiovascular programs at Brigham and Women’s Heart & Vascular Center and professor of medicine at Harvard Medical School, wrote: “These results help affirm CABG as the treatment of choice when revascularization in patients with complex multivessel disease and diabetes is deemed to be necessary, assuming the patient is an appropriate surgical candidate. ... Although the revascularization gap in favor of CABG over PCI has narrowed somewhat with newer-generation drug-eluting stents, the mortality gap has not.”

He concluded: “In general, with increasing angiographic lesion complexity, the scales tip toward CABG. Advances in medical therapy and PCI might change this calculus, but in the absence of long-term data from randomized clinical trials, the results of this pooled analysis should set the current standard.” – by Erik Swain

Disclosures: Head reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Bhatt reports he has financial ties with numerous pharmaceutical and device companies.