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Outcomes According to Coronary Disease Complexity and Optimal Thresholds to Guide Revascularization Approach: FAME 3
Luke P Dawson1, Yuhei Kobayashi2, Frederik M Zimmermann3
1Stanford University School of Medicine, Stanford, California, USA; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
Insights
Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) show comparable outcomes for multivessel disease (MVD) patients with SYNTAX scores up to 24. This finding expands the criteria for considering PCI as a viable alternative to CABG.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Coronary disease complexity influences revascularization strategy decisions in multivessel disease (MVD).
- Current guidelines often use coronary complexity scores to guide treatment choices between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG).
Purpose of the Study:
- To evaluate the impact of coronary complexity on PCI and CABG outcomes.
- To determine the optimal threshold for SYNTAX score (SS) where PCI is a reasonable alternative to CABG in MVD patients without left main disease.
Main Methods:
- Analysis of 1,444 MVD patients from the FAME 3 randomized trial (710 CABG vs. 734 PCI).
- SYNTAX scores (SS) were analyzed using restricted cubic splines and logistic regression with interaction terms.
- Cox regression models identified optimal SS thresholds for comparable outcomes between PCI and CABG.
Main Results:
- A mean SS of 25.9 ± 7.1 was observed.
- Significant interactions between revascularization strategy and SS for 1- and 3-year composite endpoints (P < 0.05).
- Outcomes were comparable for PCI and CABG up to an SS of 24 (P=0.332), a threshold encompassing 44% of patients.
Conclusions:
- PCI and CABG demonstrate comparable outcomes in MVD patients (without left main disease) for SS values up to the mid-20s.
- An SS threshold of 24 allows for the identification of a larger patient group suitable for PCI as an alternative to CABG.
Background:
Coronary disease complexity is commonly used to guide revascularization strategy in patients with multivessel disease (MVD).
Objectives:
The aim of this study was to assess the interactive effects of coronary complexity on percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) outcomes and identify the optimal threshold at which PCI can be considered a reasonable option.
Methods:
A total of 1,444 of 1,500 patients with MVD from the FAME (Fractional Flow Reserve versus Angiography for Multi-vessel Evaluation) 3 randomized trial were included in the analysis (710 CABG vs 734 PCI). SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were transformed into restricted cubic splines, and logistic regression models were fitted, with multiplicative interaction terms for revascularization strategy. Optimal thresholds at which PCI is a reasonable alternative to CABG were determined on the basis of Cox regression model performance.
Results:
The mean SYNTAX score (SS) was 25.9 ± 7.1. SS was associated with 1-year major adverse cardiac and cerebrovascular events among PCI patients and 3-year death, myocardial infarction, and stroke among CABG patients. Significant interactions were present between revascularization strategy and SS for 1- and 3-year composite endpoints (P for interaction <0.05 for all). In Cox regression models, outcomes were comparable between CABG and PCI for the 3-year primary endpoint for SS ≤24 (P = 0.332), with 44% of patients below this threshold and 32% below the conventional SS threshold of ≤22.
Conclusions:
In patients with MVD without left main disease, PCI and CABG outcomes remain comparable up to SS values in the mid- rather than low 20s, which allows the identification of a greater proportion of patients in whom PCI may be a reasonable alternative to CABG.
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