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Published on: March 27, 2018
Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass
Dena M Bravata1, Allison L Gienger, Kathryn M McDonald
1Center for Primary Care and Outcomes Research and Stanford University School of Medicine, Stanford, California 94305-6019, USA. dbravata@stanford.edu
Insights
Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) showed similar 10-year survival rates. CABG offered better angina relief but increased stroke risk, while PCI required more repeat procedures.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients with feasible revascularization options is not well-established.
- Understanding the long-term outcomes of these revascularization strategies is crucial for clinical decision-making.
Purpose of the Study:
- To compare the effectiveness of PCI and CABG in patients indicated for coronary revascularization.
- To evaluate differences in survival, angina relief, procedural complications, and need for repeat revascularization between PCI and CABG.
Main Methods:
- A systematic review of randomized controlled trials (RCTs) and selected observational studies published between 1966 and 2006 was conducted.
- Data extraction focused on study design, patient characteristics, interventions, and clinical outcomes, including survival, stroke, angina, and revascularization rates.
Main Results:
- Ten-year survival rates were similar (<1% difference) between PCI and CABG, even in diabetic patients.
- CABG provided superior angina relief (84% vs. 79% at 5 years) but was associated with a higher risk of procedural stroke (1.2% vs. 0.6%).
- PCI required significantly more repeat revascularizations (33% at 5 years) compared to CABG (9.8% at 5 years).
Conclusions:
- CABG is more effective for angina relief and reduces the need for repeat revascularization compared to PCI, but carries a higher risk of procedural stroke.
- Overall 10-year survival is comparable between the two procedures.
- Limitations include the selection of patients and centers in RCTs, and the limited use of newer technologies like drug-eluting stents.
Background:
The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood.
Purpose:
To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated.
Data Sources:
MEDLINE, EMBASE, and Cochrane databases (1966-2006); conference proceedings; and bibliographies of retrieved articles.
Study Selection:
Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.
Data Extraction:
Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.
Data Synthesis:
The authors identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedure-related strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG-PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.
Limitations:
The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.
Conclusion:
Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures.
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