Stent versus Coronary Artery Bypass Surgery in Multi-Vessel and Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Trials with Subgroups Evaluation
Pedro José Negreiros de Andrade1,2, João Luiz de Alencar Araripe Falcão1,2, Breno de Alencar Araripe Falcão1,2
1Hospital Dr. Carlos Alberto Studart Gomes de Messejana, Fortaleza, CE - Brazil.
Insights
Percutaneous coronary intervention (PCI) using stents offers lower short-term mortality and stroke rates compared to Coronary Artery Bypass Grafting (CABG). However, CABG shows better long-term survival, especially for diabetic patients.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Evidence-Based Medicine
Background:
- The optimal revascularization strategy for multi-vessel and unprotected left main coronary artery disease (LMCAD) between percutaneous coronary intervention (PCI) using stents and Coronary Artery Bypass Grafting (CABG) remains a subject of debate.
- This study addresses the controversial comparison of PCI versus CABG in treating complex coronary artery disease.
Purpose of the Study:
- To perform a systematic review and meta-analysis comparing PCI with stents versus CABG.
- To evaluate short-term and long-term outcomes, including mortality and stroke incidence, in patients undergoing PCI or CABG for multi-vessel and unprotected LMCAD.
Main Methods:
- A systematic search of electronic databases identified 15 randomized controlled trials (RCTs) comparing PCI with stents versus CABG.
- Data from 12,781 patients were pooled for meta-analysis, with statistical significance set at p < 0.05.
- Subgroup analyses were conducted for diabetic patients and those with LMCAD.
Main Results:
- Pooled data revealed lower 30-day mortality (1% vs 1.7%) and stroke rates (0.6% vs 1.7%) with PCI compared to CABG.
- No significant differences in one- and two-year mortality were observed between the two interventions.
- Long-term mortality favored CABG (10.6% vs 9.4%), particularly in the Drug-Eluting Stent (DES) era and in diabetic patients (13.7% vs 10.3%).
- For LMCAD, PCI showed a lower stroke incidence (0.3% vs 1.5%) without significant differences in mortality outcomes.
- Diabetes and high SYNTAX scores were identified as factors adversely impacting PCI outcomes.
Conclusions:
- PCI with stents demonstrates reduced 30-day mortality and stroke incidence relative to CABG.
- CABG is associated with improved long-term survival, especially in diabetic patients and those with complex disease.
- The choice between PCI and CABG should consider patient-specific factors like diabetes and coronary anatomy (SYNTAX score).
Background:
Comparison between percutaneous coronary intervention (PCI) using stents and Coronary Artery Bypass Grafting (CABG) remains controversial.
Objective:
To conduct a systematic review with meta-analysis of PCI using Stents versus CABG in randomized controlled trials.
Methods:
Electronic databases were searched to identify randomized trials comparing PCI using Stents versus CABG for multi-vessel and unprotected left main coronary artery disease (LMCAD). 15 trials were found and their results were pooled. Differences between trials were considered significant if p < 0.05.
Results:
In the pooled data (n = 12,781), 30 days mortality and stroke were lower with PCI (1% versus 1.7%, p = 0.01 and 0.6% versus 1.7% p < 0.0001); There was no difference in one and two year mortality (3.3% versus 3.7%, p = 0.25; 6.3% versus 6.0%, p = 0.5). Long term mortality favored CABG (10.6% versus 9.4%, p = 0.04), particularly in trials of DES era (10.1% versus 8.5%, p = 0.01). In diabetics (n = 3,274) long term mortality favored CABG (13.7% versus 10.3%; p < 0.0001). In six trials of LMCAD (n = 4,700) there was no difference in 30 day mortality (0.6%versus 1.1%, p = 0.15), one year mortality (3% versus 3.7%, p = 0.18), and long term mortality (8.1% versus 8.1%) between PCI and CABG; the incidence of stroke was lower with PCI (0.3% versus 1.5%; p < 0.001). Diabetes and a high SYNTAX score were the subgroups that influenced more adversely the results of PCI.
Conclusion:
Compared with CABG, PCI using Stents showed lower 30 days mortality, higher late mortality and lower incidence of stroke. Diabetes and a high SYNTAX were the subgroups that influenced more adversely the results of PCI.
Related Concept Videos
01:30Coronary Artery Disease I: Introduction
01:26Coronary Artery Disease II: Pathophysiology
01:27Coronary Artery Disease V: Interprofessional Care
01:30Coronary Artery Disease III: Clinical Manifestations
01:26Coronary Artery Disease IV: Preventive Measures
01:21Peripheral Arterial Disease II: Clinical Manifestations and Diagnostic Evaluation