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Outcomes After CABG Compared With FFR-Guided PCI in Patients Presenting With Acute Coronary Syndrome
Kuniaki Takahashi1, Hisao Otsuki1, Frederik M Zimmermann2
1Stanford University School of Medicine and Stanford Cardiovascular Institute, Stanford University, California, USA.
Insights
Coronary artery bypass grafting (CABG) showed similar outcomes to fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients at 3 years. CABG reduced risks for chronic coronary syndrome patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Limited comparative data exist for coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients.
- The FAME 3 trial provides crucial insights into treatment outcomes for multivessel coronary artery disease.
Purpose of the Study:
- To compare outcomes of CABG versus fractional flow reserve (FFR)-guided PCI with drug-eluting stents in patients with NSTE-ACS.
- To evaluate differences in major adverse cardiac events between CABG and FFR-guided PCI across different patient presentations.
Main Methods:
- The FAME 3 randomized controlled trial enrolled 1,500 patients with 3-vessel coronary artery disease.
- Patients were randomized to receive either CABG or FFR-guided PCI using current-generation drug-eluting stents.
- Outcomes were assessed at 1 year (primary endpoint) and 3 years (key secondary endpoint) for death, myocardial infarction (MI), stroke, or repeat revascularization.
Main Results:
- Of 1,500 patients, 587 (39.2%) presented with NSTE-ACS. At 3 years, the composite risk of death, MI, or stroke was similar between NSTE-ACS and chronic coronary syndrome (CCS) patients.
- Patients with NSTE-ACS showed similar rates of death, MI, or stroke after CABG compared to PCI (adjusted HR: 0.98).
- Patients with CCS experienced a significantly reduced risk of death, MI, or stroke after CABG compared to PCI (adjusted HR: 0.58), driven by a lower MI risk.
Conclusions:
- CABG and FFR-guided PCI yielded similar 3-year risks of death, MI, or stroke in patients presenting with NSTE-ACS.
- CABG demonstrated a significant benefit in reducing the risk of death, MI, or stroke for patients presenting with CCS compared to PCI.
- These findings highlight the importance of treatment strategy based on acute presentation in multivessel coronary artery disease.
Background:
There are limited data comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) in patients presenting with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).
Objectives:
The aim of this study was to evaluate differences in outcomes in patients presenting with or without NSTE-ACS after CABG compared with fractional flow reserve (FFR)-guided PCI using current generation drug-eluting stents.
Methods:
The FAME 3 trial (Fractional flow reserve versus Angiography for Multivessel Evaluation; NCT02100722) was an investigator-initiated, randomized controlled trial to attest noninferiority of FFR-guided PCI using the current-generation drug-eluting stents to CABG with respect to the primary endpoint, defined as a composite of death, myocardial infarction (MI), stroke, or repeat revascularization at 1 year, in 1,500 patients with 3-vessel coronary artery disease. The prespecified key secondary endpoint was a composite of death, MI, or stroke at 3 years.
Results:
Of 1,500 patients enrolled, 587 (39.2%) presented with NSTE-ACS. Patients were followed up for a median of 1,080 days (Q1-Q3: 1,080-1,080 days). At 3 years, the risk of the composite of death, MI, or stroke was similar between patients presenting with NSTE-ACS and with chronic coronary syndrome (CCS) (11.8% vs 10.0%; adjusted HR [aHR]: 1.20; 95% CI: 0.81-1.77; P = 0.37). Patients presenting with NSTE-ACS had a similar risk of death, MI, or stroke at 3 years after CABG as compared with PCI (aHR: 0.98; 95% CI: 0.60-1.60; P = 0.94), whereas patients presenting with CCS had a significantly reduced risk after CABG compared with PCI (aHR: 0.58; 95% CI: 0.38-0.90; P = 0.02; Pinteraction = 0.11), which was driven by a lower risk of MI (aHR: 0.32; 95% CI: 0.15-0.64; P = 0.002; Pinteraction = 0.01).
Conclusions:
The risk of death, MI, or stroke at 3 years was similar after CABG compared with FFR-guided PCI in patients presenting with NSTE-ACS, but reduced by CABG in patients presenting with CCS. (Fractional flow reserve versus Angiography for Multivessel Evaluation [FAME 3]; NCT02100722).
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