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Published on: January 18, 2018
Comparative effectiveness of revascularization strategies
William S Weintraub1, Maria V Grau-Sepulveda, Jocelyn M Weiss
1Christiana Care Health System, Newark, DE 19718, USA. wweintraub@christianacare.org
Insights
Coronary artery bypass grafting (CABG) showed a long-term survival advantage over percutaneous coronary intervention (PCI) for older patients with multivessel coronary artery disease. This finding supports CABG for non-emergency cases.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Comparative effectiveness of percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG) remains a significant clinical question.
- The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) initiated a study to compare long-term survival rates.
- Existing data lack definitive long-term comparative outcomes for these revascularization strategies.
Purpose of the Study:
- To compare the long-term survival rates of patients undergoing PCI versus CABG.
- To evaluate the effectiveness of two major coronary revascularization procedures in a large, real-world patient population.
- To provide evidence to guide clinical decision-making for patients with multivessel coronary artery disease.
Main Methods:
- Linked data from ACCF National Cardiovascular Data Registry, STS Adult Cardiac Surgery Database, and Medicare claims (2004-2008).
- Utilized propensity score and inverse-probability-weighting adjustments to mitigate treatment-selection bias.
- Conducted a sensitivity analysis to assess residual confounding.
Main Results:
- Among 86,244 CABG and 103,549 PCI patients (≥65 years, multivessel disease without acute myocardial infarction), no significant 1-year mortality difference was observed (6.24% vs. 6.55%).
- At 4 years, CABG demonstrated significantly lower mortality (16.4%) compared to PCI (20.8%), with a risk ratio of 0.79.
- Consistent findings were observed across multiple subgroups and analytical methods.
Conclusions:
- Coronary artery bypass grafting (CABG) is associated with a long-term survival advantage compared to percutaneous coronary intervention (PCI).
- This advantage was observed in older patients with multivessel coronary artery disease not requiring emergency intervention.
- The findings suggest CABG may be a preferred revascularization strategy for this patient cohort in the long term.
Background:
Questions persist concerning the comparative effectiveness of percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG). The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) collaborated to compare the rates of long-term survival after PCI and CABG.
Methods:
We linked the ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008. Outcomes were compared with the use of propensity scores and inverse-probability-weighting adjustment to reduce treatment-selection bias.
Results:
Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results were noted in multiple subgroups and with the use of several different analytic methods. Residual confounding was assessed by means of a sensitivity analysis.
Conclusions:
In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI. (Funded by the National Heart, Lung, and Blood Institute.).
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