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Published on: March 27, 2018
Coronary artery bypass grafting vs percutaneous coronary intervention in a 'real-world' setting: a comparative
Daniela Fortuna1, Francesco Nicolini, Paolo Guastaroba
1Regional Agency for Health and Social Care of Emilia-Romagna, Bologna, Italy. dfortuna@regione.emilia-romagna.it
Insights
Coronary artery bypass grafting (CABG) showed better long-term outcomes than percutaneous coronary intervention (PCI) for patients with left main or multivessel disease. CABG significantly reduced rates of death, myocardial infarction, and target vessel revascularization.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are common revascularization strategies.
- Previous studies suggest CABG may lead to fewer repeat revascularizations, but long-term real-world data for complex cases are limited.
Purpose of the Study:
- To compare 5-year outcomes of CABG versus PCI in patients with left main coronary artery (LMCA) or multivessel disease.
- To evaluate rates of death, myocardial infarction (MI), target vessel revascularization (TVR), and stroke.
Main Methods:
- Utilized propensity score-matched cohorts from a large regional registry (July 2002-December 2008).
- Compared 6,246 patients undergoing PCI with 5,504 patients undergoing CABG.
- Included patients with LMCA or multivessel disease where both procedures were technically feasible.
Main Results:
- CABG was associated with significantly lower 5-year risks of death (HR=1.6), MI (HR=3.3), and TVR (HR=4.5) compared to PCI.
- No significant difference in stroke rates was observed between CABG and PCI (HR=1.1).
- CABG demonstrated greater benefit in reducing mortality for patients with LMCA, three-vessel disease, reduced LVEF, heart failure, or diabetes.
Conclusions:
- In a real-world setting, CABG is associated with superior long-term outcomes compared to PCI for patients with LMCA or multivessel disease.
- CABG remains the standard of care, especially for patients with extensive coronary disease and diabetes.
- The observed mortality benefit with CABG is largely attributed to a lower rate of MI compared to PCI.
Objectives:
Most studies comparing coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) showed that fewer patients who had undergone CABG required repeat revascularizations , but no difference in survival, with the exception of some subgroups of patients. However, long-term real-world evidence on patients in whom both procedures are technically feasible is yet not available. The aim of this study was to compare 5-year rates of death, myocardial infarction (MI), target vessel revascularization (TVR) and stroke in a large cohort of patients with left main coronary artery (LMCA) or multivessel disease, treated with CABG or PCI (with or without DES) or PCI with DES only.
Methods:
Two propensity score (PS)-matched cohorts of patients undergoing revascularization procedures at the regional public and private centres of Emilia-Romagna over the period July 2002-December 2008 were used to compare long-term outcomes of PCI (6246 patients) and CABG (5504 patients).
Results:
PCI was associated with higher risk of death (HR = 1.6; 95% CI 1.4-1.8, P < 0.0001), MI (HR = 3.3; 95% CI 2.7-4.0, P < 0.0001) and TVR (HR = 4.5; 95% CI 3.8-5.2, P < 0.0001) at 5 years. No significant difference was shown for stroke (HR = 1.1; 95% CI 0.9-1.4, P = 0.43). CABG benefit was more evident in the risk of death in patients with two-vessel disease plus LMCA and in those with three-vessel disease, LVEF <35%, congestive heart failure and diabetes. Adjusted comparison with PS between PCI with DES only and CABG confirmed significant differences in favour of CABG for mortality, MI and TVR rates. Competing risk analysis showed that the difference in the mortality rate was due to higher rate of MI in PCI.
Conclusions:
In the 'real-world' setting of this study, CABG was associated with significantly lower rates of death, MI and TVR in patients with LMCA or multivessel disease, so it remains the standard of care, particularly for patients with more extensive coronary disease and diabetes.
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