Comparative effectiveness of revascularization strategies for early coronary artery disease: A multicenter analysis
Michael P Robich1, Bruce J Leavitt2, Thomas J Ryan1
1Maine Medical Partners, Maine Medical Center, Portland, Me.
Insights
For patients under 60, coronary artery bypass grafting offers superior 10-year survival and lower repeat revascularization rates compared to percutaneous coronary intervention. Surgery showed a higher risk of stroke but better long-term outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Coronary artery disease (CAD) is a leading cause of mortality worldwide.
- Revascularization strategies, including coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), are crucial for managing severe CAD.
- Comparative effectiveness of these strategies in younger patient populations (under 60) requires further investigation.
Purpose of the Study:
- To compare the long-term effectiveness of CABG versus PCI in patients younger than 60 years with significant coronary artery stenosis.
- To evaluate differences in mortality, stroke, and repeat revascularization rates between the two treatment groups.
Main Methods:
- A multicenter, retrospective analysis of cardiac revascularization procedures between 2005 and 2015.
- Inclusion criteria: age < 60 years, 70% stenosis in major coronary arteries. Exclusion criteria: left main disease, STEMI, emergency procedures, prior revascularization.
- Study cohort: 1945 patients for surgery (CABG) and 2938 for PCI. Inverse probability weighting was used for group balancing.
Main Results:
- No significant difference in 30-day mortality between CABG and PCI for multivessel disease.
- CABG was associated with a higher risk of stroke (1.3% vs 0.07%).
- CABG demonstrated superior 10-year survival (HR 0.71) and a significantly lower cumulative incidence of repeat revascularization over 10 years (SHR 0.34) compared to PCI.
Conclusions:
- In patients under 60 with 2-vessel disease (including LAD) or 3-vessel disease, CABG is linked to better long-term survival.
- CABG also reduces the risk of repeat revascularization compared to PCI in this demographic.
- While stroke risk is higher with surgery, the long-term benefits in survival and need for further procedures favor CABG.
Objectives:
The goal of this analysis was to examine the comparative effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention among patients aged less than 60 years.
Methods:
We performed a multicenter, retrospective analysis of all cardiac revascularization procedures from 2005 to 2015 among 7 medical centers. Inclusion criteria were age less than 60 years and 70% stenosis or greater in 1 or more major coronary artery distribution. Exclusion criteria were left main 50% or greater, ST-elevation myocardial infarction, emergency status, and prior revascularization procedure. After applying inclusion and exclusion criteria, the final study cohort included 1945 patients who underwent cardiac surgery and 2938 patients who underwent percutaneous coronary intervention. The primary end point was all-cause mortality stratified by revascularization strategy. Secondary end points included stroke, repeat revascularization, and 30-day mortality. We used inverse probability weighting to balance differences among the groups.
Results:
After adjustment, there was no significant difference in 30-day mortality (surgery: 0.8%; percutaneous coronary intervention: 0.7%, P = .86) for patients with multivessel disease. Patients undergoing surgery had a higher risk of stroke (1.3% [n = 25] vs 0.07% [n = 2], P < .001). Overall, surgery was associated with superior 10-year survival compared with percutaneous coronary intervention (hazard ratio, 0.71; 95% confidence interval, 0.57-0.88; P = .002). Repeat procedures occurred in 13.4% (n = 270) of the surgery group and 36.4% (n = 1068) of the percutaneous coronary intervention group, with both groups mostly undergoing percutaneous coronary intervention as their second operation. Accounting for death as a competing risk, at 10 years, surgery resulted in a lower cumulative incidence of repeat revascularization compared with percutaneous coronary intervention (subdistribution hazard ratio, 0.34; 95% confidence interval, 0.28-0.40; P < .001).
Conclusions:
Among patients aged less than 60 years with 2-vessel disease that includes the left anterior descending or 3-vessel coronary artery disease, surgery was associated with greater long-term survival and decreased risk of repeat revascularization.
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