Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease - Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease

Description:

Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease.

Hypothesis:

What are the relative benefits of bypass surgery (CABG) and percutaneous intervention with stenting for multivessel coronary artery disease (CAD) in terms on improving short- and long-term outcomes?

Study Design

Study Design:

Patients Enrolled: 1205
Mean Follow Up: 1 year

Drug/Procedures Used:

Patients with multivessel CAD (n=1205) were randomly assigned to undergo stent implantation or CABG when a cardiac surgeon and an interventional cardiologist concurred that the same extent of revascularization could be achieved by either technique.

Principal Findings:

At 1 year, there were no significant differences between the two groups in terms of the rates of death, stroke or myocardial infarction (primary end point). Among patients who survived without a stroke or a myocardial infarction, 16.8% of those in the stent group underwent a second revascularization, as compared with 3.5% of those in the surgery group. Event-free survival at 1 year was 73.8% among stent patients and 87.8% among CABG patients (p<0.001). The initial difference in cost ($4,212 less for stent patients) was reduced during follow-up because of the increased need for repeat revascularization in the stent group. After 1 year, the net difference in favor of stenting was estimated to be $2,973/patient. Multivariate analysis identified that an elevated level of CK MB was the main predictor of poorer outcome in the surgical group whereas diabetes correlated with poorer outcome in the stent group.

As measured 1 year after the procedure, coronary stenting for multivessel CAD is less expensive than CABG and offers the same degree of protection against death, stroke, and myocardial infarction. However, stenting is associated with a greater need for repeat revascularization.

Interpretation:

Several features need to be considered when interpreting the findings of this study. First, patients with ejection fractions <30% were excluded and only 1-year outcomes were reported. Thus, extrapolation as to the relative benefits of stents vs. CABG in patients with poor LV function and for long-term outcomes (beyond 1 year) should not be made. Further glycoprotein IIbIIIa inhibitors were not utilized, which might have decreased the 2.8% stent thrombosis rate and the 30% CK MB release in the stent patients in this study. Finally, in patients undergoing CABG elevated CK MB (observed in 61% of patients, 12.6% with >5 times normal) was an independent predictor of adverse clinical events emphasizing the need for better myocardial preservation techniques.

References:

1. Serruys PW, Unger F, Sousa F, et al., for the Arterial Revascularization Therapies Study Group. N Engl J Med 2001;344:1117-24.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Myocardial Infarction, Stroke, Multivariate Analysis, Thrombosis, Creatine Kinase, MB Form, Disease-Free Survival, Coronary Artery Bypass, Diabetes Mellitus, Stents


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