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Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a
Mark A Hlatky1, Derek B Boothroyd, Dena M Bravata
1Stanford University School of Medicine, Stanford, CA, USA.
Insights
Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) show similar long-term mortality for most multivessel coronary disease patients. However, CABG may offer better survival for patients with diabetes and those aged 65 or older.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are primary treatments for multivessel coronary disease.
- Long-term mortality differences between CABG and PCI in specific patient subgroups remain unclear.
Purpose of the Study:
- To collaboratively analyze randomized trial data to compare long-term mortality outcomes between CABG and PCI.
- To investigate if patient characteristics modify the treatment effects on mortality.
Main Methods:
- Pooled individual patient data from ten randomized trials involving 7812 patients.
- Used intention-to-treat analysis with stratified, random effects Cox proportional hazards models.
- Examined treatment effects on all-cause mortality and their interaction with baseline clinical characteristics.
Main Results:
- Overall long-term mortality was similar between CABG and PCI (HR 0.91, p=0.12).
- CABG demonstrated significantly lower mortality in patients with diabetes (HR 0.70) and those aged 65 or older (HR 0.82).
- Mortality was similar between treatments for patients without diabetes and those younger than 65, with significant interactions for diabetes and age (p=0.014 and p=0.002, respectively).
Conclusions:
- Long-term mortality is comparable for CABG and PCI in most multivessel coronary disease patients.
- Treatment decisions should consider patient preferences for other outcomes.
- CABG may be preferable for patients with diabetes and elderly patients (≥65 years) due to observed lower mortality rates in these groups.
Background:
Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are alternative treatments for multivessel coronary disease. Although the procedures have been compared in several randomised trials, their long-term effects on mortality in key clinical subgroups are uncertain. We undertook a collaborative analysis of data from randomised trials to assess whether the effects of the procedures on mortality are modified by patient characteristics.
Methods:
We pooled individual patient data from ten randomised trials to compare the effectiveness of CABG with PCI according to patients' baseline clinical characteristics. We used stratified, random effects Cox proportional hazards models to test the effect on all-cause mortality of randomised treatment assignment and its interaction with clinical characteristics. All analyses were by intention to treat.
Findings:
Ten participating trials provided data on 7812 patients. PCI was done with balloon angioplasty in six trials and with bare-metal stents in four trials. Over a median follow-up of 5.9 years (IQR 5.0-10.0), 575 (15%) of 3889 patients assigned to CABG died compared with 628 (16%) of 3923 patients assigned to PCI (hazard ratio [HR] 0.91, 95% CI 0.82-1.02; p=0.12). In patients with diabetes (CABG, n=615; PCI, n=618), mortality was substantially lower in the CABG group than in the PCI group (HR 0.70, 0.56-0.87); however, mortality was similar between groups in patients without diabetes (HR 0.98, 0.86-1.12; p=0.014 for interaction). Patient age modified the effect of treatment on mortality, with hazard ratios of 1.25 (0.94-1.66) in patients younger than 55 years, 0.90 (0.75-1.09) in patients aged 55-64 years, and 0.82 (0.70-0.97) in patients 65 years and older (p=0.002 for interaction). Treatment effect was not modified by the number of diseased vessels or other baseline characteristics.
Interpretation:
Long-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes. CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups.
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