Comparison of Stenting Versus Bypass Surgery According to the Completeness of Revascularization in Severe Coronary Artery Disease: Patient-Level Pooled Analysis of the SYNTAX, PRECOMBAT, and BEST Trials.

Abstract

OBJECTIVES:

The aim of this study was to compare long-term survival between patients with severe coronary artery disease undergoing coronary artery bypass grafting (CABG) and those undergoing percutaneous coronary intervention (PCI) achieving complete revascularization (CR) or incomplete revascularization.

BACKGROUND:

The importance of CR in decision making regarding revascularization strategy in patients with severe coronary artery disease is unknown.

METHODS:

Data were pooled from the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery), PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease), and BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease) trials. The primary outcome was death from any cause and was compared in an as-treated analysis.

RESULTS:

The rate of CR was 61.7% (57.2% with PCI and 66.8% with CABG). During a median 4.9-year follow-up period (interquartile range: 4.5 to 5.0 years), compared with patients undergoing CABG with CR, those undergoing PCI with incomplete revascularization had a higher risk for death from any cause (adjusted hazard ratio [aHR]: 1.43; 95% confidence interval [CI]: 1.03 to 2.00; p = 0.036) and the composite of death, myocardial infarction, and stroke (aHR: 1.48; 95% CI: 1.14 to 1.92; p = 0.003). However, there was no significant difference between patients undergoing CABG with CR and those undergoing PCI with CR regarding the risk for death from any cause (aHR: 1.16; 95% CI: 0.83 to 1.63; p = 0.39) and the composite of death, myocardial infarction, and stroke (aHR: 1.14; 95% CI: 0.87 to 1.48; p = 0.35). Subgroup analysis of multivessel coronary disease, high SYNTAX score (>32), and diabetes showed consistent findings.

CONCLUSIONS:

For the treatment of left main or multivessel coronary artery disease, PCI resulting in CR was associated with a similar long-term survival rate to CABG resulting in CR. Therefore, the ability to achieve CR should enter into the decision algorithm for choice of revascularization strategy.

• Authors: Jung-Min Ahn, Duk-Woo Park, Cheol Whan Lee, Mineok Chang, Rafael Cavalcante, Yohei Sotomi, Yoshinobu Onuma, Erhan Tenekecioglu, Minkyu Han, Pil Hyung Lee, Soo-Jin Kang, Seung-Whan Lee, Young-Hak Kim, Seong-Wook Park, Patrick W Serruys, Seung-Jung Park
• Journal: JACC. Cardiovascular interventions (JACC Cardiovasc Interv) Vol. 10 Issue 14 Pg. 1415-1424 (07 24 2017) ISSN: 1876-7605 [Electronic] United States
• PMID: 28728654 (Publication Type: Comparative Study, Journal Article, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2017. Published by Elsevier Inc.

Topics

• Aged
• Algorithms
• Clinical Decision-Making
• Coronary Artery Bypass (adverse effects, mortality)
• Coronary Artery Disease (diagnostic imaging, mortality, surgery, therapy)
• Decision Support Techniques
• Female
• Humans
• Kaplan-Meier Estimate
• Male
• Middle Aged
• Myocardial Infarction (etiology)
• Percutaneous Coronary Intervention (adverse effects, instrumentation, mortality)
• Proportional Hazards Models
• Randomized Controlled Trials as Topic
• Risk Factors
• Severity of Illness Index
• Stents
• Stroke (etiology)
• Time Factors
• Treatment Outcome