CABG tops PCI for nondiabetic patients with multivessel CAD

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The jury is still out

It is important to consider some limitations of the current study. First, the majority of patients were derived from the SYNTAX trial, which used first-generation paclitaxel drug-eluting stents (DES) that exhibit higher stent complication rates compared with current second- and third-generation everolimus-eluting stents. Second, although complete revascularization was more frequently obtained with CABG in the SYNTAX and BEST trials, current PCI approaches are narrowing this gap with chronic total occlusion PCI techniques and temporary hemodynamic support when needed. Third, selection bias may limit the applicability of these results to patients with more complex disease who are often excluded from clinical trials and may not be eligible for CABG.

Therefore, an adequately powered study of contemporary DES PCI versus CABG is warranted for real-world, nondiabetic patients with multivessel CAD. Guidelines and meta-analyses provide valuable recommendations for populations at large, but decision making for nondiabetic patients with multivessel CAD should be individualized. If equipoise between CABG and PCI exists, decision-making can be improved by engaging a local multidisciplinary CAD heart team. Well-informed cardiologists, interventionalists, and cardiac surgeons who engage in multidisciplinary heart team evaluations and patient-centered shared decision making will provide optimal guidance for patients with multivessel CAD.

Farouc A. Jaffer, MD, is at Massachusetts General Hospital; Patrick T. O’Gara, MD, is at Brigham and Women’s Hospital, both in Boston. Dr. Jaffer disclosed research grants from Siemens and Kowa and consulting relationships with Boston Scientific and Abbott Vascular. Dr. O’Gara had no disclosures. These comments are from their editorial (J Am Coll Cardiol. 2016 Jun 27. doi: 10.1016/j.jacc.2016.05.008).




Coronary artery bypass graft surgery was associated with a 35% lower rate of all-cause mortality rate and a 59% lower rate of cardiac death than was percutaneous coronary intervention in a pooled analysis of nondiabetic patients with multivessel coronary artery disease in two international randomized trials.

“The superiority of CABG over PCI was consistent across all major clinical subgroups. Likewise, the rate of myocardial infarction was remarkably lower after CABG than after PCI,” Mineok Chang, MD, of the University of Ulsan in Seoul, South Korea, and her associates reported online June 27 in the Journal of the American College of Cardiology.

The advent of drug-eluting stents has led to widespread use of PCI, but controversy persists regarding the best revascularization strategy for nondiabetic patients with multivessel CAD, the researchers said. All-cause mortality “is undoubtedly the most unbiased endpoint to determine treatment strategy,” but individual trials have lacked the power to evaluate this endpoint, they added. Accordingly, they pooled data from the SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) trial – which included 1,800 patients with three-vessel or left main CAD from Europe and the United States – and from the BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease) trial, which included 880 patients from Asia with two- or three-vessel CAD. Excluding patients with left main CAD or diabetes left 1,275 patients for analysis (J Am Coll Cardiol. 2016 Jun 27. 68:29-36).

After a median follow-up of 61 months, 38 (6%) CABG patients had died, compared with 59 (9.3%) PCI patients, for a statistically significant hazard ratio of 0.65 (95% confidence interval, 0.25-0.78; P = .039). Likewise, cardiac death was significantly less likely after CABG than PCI (HR, 0.41; 95% CI, 0.25-0.78; P = .005). “The statistical difference between the two groups was pronounced after 2 years of randomization for both all-cause and cardiac mortality,” the researchers reported. Although the latest drug-eluting stents “are reported to improve clinical outcomes,” they did not find a significant interaction between older and more recently developed stents when considering all-cause mortality, they noted.

The study was supported by a research grant from the CardioVascular Research Foundation in Seoul, South Korea. Dr. Chang had no disclosures. Senior author, Dr. Seung-Jung Park, disclosed research support from Abbott Vascular, Cordis, Boston Scientific, and Medtronic.

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