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Updated: Jun 30, 2025
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Choice of revascularization strategy for ischemic cardiomyopathy due to multivessel coronary disease
Anas H Alzahrani1, Shinobu Itagaki2, Natalia N Egorova3
1Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
Insights
Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) show similar long-term mortality for ischemic cardiomyopathy. CABG reduces repeat revascularization, supporting its use in multivessel disease with reduced ejection fraction.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Multivessel revascularization decisions for ischemic cardiomyopathy lack robust comparative data.
- Optimal treatment strategy between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) remains debated.
Purpose of the Study:
- To compare the long-term outcomes of CABG versus PCI in patients with ischemic cardiomyopathy and multivessel coronary disease.
Main Methods:
- A retrospective analysis of linked clinical registries and administrative databases from New Jersey (2007-2018).
- Included 5988 patients with ejection fraction ≤35% undergoing CABG or PCI.
- Used Cox proportional hazards and propensity matching with competing risk analysis for outcomes including mortality, repeat revascularization, heart failure readmissions, myocardial infarction, and stroke.
Main Results:
- At 13 years, no significant difference in all-cause mortality between PCI and CABG (57% vs. 60%, P=.28).
- PCI had a higher risk of repeat revascularization (18% vs. 14%, P=.003) and myocardial infarction (10% vs. 6%, P=.007).
- Complete revascularization rates were lower with PCI and associated with higher mortality.
Conclusions:
- CABG demonstrated similar long-term mortality, stroke, and heart failure readmission rates compared to PCI.
- CABG was associated with significantly reduced rates of repeat revascularization.
- Findings support CABG for patients with multivessel coronary disease and left ventricular dysfunction, particularly when complete revascularization is prioritized.
Objective:
Limited comparative data guide the decision between coronary artery bypass grafting and percutaneous coronary intervention for multivessel revascularization in ischemic cardiomyopathy. The study objective was to compare the long-term outcomes of coronary artery bypass grafting and percutaneous coronary intervention for ischemic cardiomyopathy.
Methods:
Clinical registries from the New Jersey Department of Health linked to administrative databases were used to compare all-cause mortality, repeat revascularization, heart failure readmissions, myocardial infarction, and stroke using Cox proportional hazards and propensity matching with competing risk analysis in 5988 patients with ejection fraction 35% or less who underwent coronary artery bypass grafting (3673, 61.3%) or percutaneous coronary intervention (2315, 38.6%) for multivessel coronary disease between 2007 and 2018. Median follow-up time was 5.2 years (range, 0-13 years); the last follow-up date was December 31, 2020.
Results:
After controlling for completeness of revascularization, at 13 years, mortality was 57% (95% CI, 51-63) after percutaneous coronary intervention and 60% (95% CI, 53-66) after coronary artery bypass grafting (hazard ratio [HR], 1.10; 95% CI, 0.93-1.31; P = .28); risk of repeat revascularization was 18% for percutaneous coronary intervention versus 14% for coronary artery bypass grafting (HR, 1.62; 95% CI, 1.17-2.25; P = .003); risk of readmission for heart failure was 16% after percutaneous coronary intervention and coronary artery bypass grafting (HR, 1.13,95% CI, 0.84-1.51, weighted P = .10); risk of myocardial infarction was 10% versus 6%, respectively (HR, 1.91; 95% CI, 1.18-3.09; P = .007); and stroke risk was 3% versus 4%, respectively (HR, 0.79; 95% CI, 0.41-1.53; P = .52). Rate of complete revascularization was lower after percutaneous coronary intervention than after coronary artery bypass grafting and associated with higher mortality after percutaneous coronary intervention (HR, 1.35; 95% CI, 1.20-1.52; P < .001).
Conclusions:
Coronary bypass was associated with similar mortality, stroke, and heart failure readmissions, and reduced repeat revascularization compared with percutaneous coronary intervention in patients with ischemic cardiomyopathy if similar rates of complete revascularization were achieved. These findings support consensus recommendations for coronary artery bypass grafting and medical therapy in patients with multivessel coronary disease and left ventricular dysfunction.
