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Surgical Swine Model of Chronic Cardiac Ischemia Treated by Off-Pump Coronary Artery Bypass Graft Surgery
Published on: March 27, 2018
Comparative effectiveness of multivessel coronary bypass surgery and multivessel percutaneous coronary intervention:
Mark A Hlatky1, Derek B Boothroyd, Laurence Baker
1Stanford University School of Medicine, Stanford, CA 94305, USA. hlatky@stanford.edu
Insights
Coronary artery bypass graft (CABG) surgery shows lower mortality than percutaneous coronary intervention (PCI) in older adults. Patient characteristics, like diabetes, significantly modify this survival benefit.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Health Services Research
Background:
- Randomized trials indicate patient characteristics influence mortality outcomes for coronary artery bypass graft (CABG) surgery versus percutaneous coronary intervention (PCI).
- Understanding these modifications is crucial for optimizing treatment decisions in diverse patient populations.
Purpose of the Study:
- To evaluate how clinical characteristics modify the comparative effectiveness of CABG and PCI in a broad patient population.
- To assess long-term mortality differences between CABG and PCI based on patient subgroups.
Main Methods:
- Observational study utilizing propensity score matching and Cox proportional hazards models.
- Analysis of Medicare beneficiaries aged 66 years or older from 1992 to 2008.
- Comparison of multivessel CABG versus multivessel PCI, assessing all-cause mortality and survival differences over 5 years.
Main Results:
- CABG was associated with significantly lower mortality than PCI (HR, 0.92; P < 0.001) in 105,156 matched patients.
- The survival benefit of CABG was significantly greater for patients with diabetes, a history of tobacco use, heart failure, or peripheral arterial disease.
- Patients with these comorbidities experienced larger predicted survival advantages with CABG compared to PCI.
Conclusions:
- Multivessel CABG demonstrates lower long-term mortality than multivessel PCI in a real-world, community setting.
- Patient characteristics, particularly diabetes, tobacco use, heart failure, and peripheral arterial disease, substantially modify the survival outcomes.
- The observed survival improvements with CABG are concentrated in specific patient subgroups, highlighting the importance of personalized treatment selection.
Background:
Randomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality.
Objective:
To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population.
Design:
Observational treatment comparison using propensity score matching and Cox proportional hazards models.
Setting:
United States, 1992 to 2008.
Patients:
Medicare beneficiaries aged 66 years or older.
Intervention:
Multivessel CABG or multivessel PCI.
Measurements:
The CABG-PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up.
Results:
Among 105 156 propensity score-matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P ≤ 0.002 for each) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-years (range, -0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI.
Limitation:
Treatments were chosen by patients and physicians rather than being randomly assigned.
Conclusion:
Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease.
Primary Funding Source:
National Heart, Lung, and Blood Institute.
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