Long-Term Comparison of Drug-Eluting Stents and Coronary Artery Bypass Grafting for Multivessel Coronary Revascularization: 5-Year Outcomes From the Asan Medical Center-Multivessel Revascularization Registry

Study Questions:

What are the long-term (5-year) outcomes of a large cohort of patients who underwent drug-eluting stent (DES) or coronary artery bypass graft (CABG) surgery for multivessel revascularization?

Methods:

The investigators evaluated 3,042 patients with multivessel disease who received DES (n = 1,547) or underwent CABG (n = 1,495) between January 2003 and December 2005, and for whom complete follow-up data were available for a median 5.6 years (interquartile range, 4.6-6.3 years). They compared adverse outcomes (death; a composite outcome of death, myocardial infarction [MI] or stroke; and repeat revascularization). Differences in risk-adjusted, long-term rates of study outcomes between patients undergoing the two procedures were assessed using multivariable Cox proportional-hazards regression.

Results:

After adjustment for differences in baseline risk factors, 5-year risk of death (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.76-1.32; p = 0.99) and the combined risk of death, MI, or stroke (HR, 0.97; 95% CI, 0.76-1.24; p = 0.81) were similar between the DES group and the CABG group. However, the rates of revascularization were significantly higher in the DES group (HR, 2.93; 95% CI, 2.20-3.90; p < 0.001). Similar results were obtained in comparisons of DES with CABG for high-risk clinical and anatomic subgroups with diabetes mellitus, abnormal ventricular function, age 65 years or more, and three-vessel and left main disease. However, mortality benefit with DES implantation relative to CABG was noted in patients with two-vessel disease (HR, 0.57; 95% CI, 0.36-0.92; p = 0.02).

Conclusions:

The authors concluded that for patients with multivessel disease, DES treatment compared with CABG, showed similar rates of mortality and of the composite safety outcomes, but higher rates of revascularization up to 5 years.

Perspective:

This observational registry suggests that for patients with multivessel disease, DES treatment has similar rates of mortality and the composite endpoint of death, MI, or stroke, as compared to bypass surgery, but higher rates of revascularization up to 5 years. It would appear that when using optimal clinical judgment of the treating physician to appropriately select patients with multivessel coronary artery disease for percutaneous coronary intervention (PCI) or bypass surgery, DES implantation is associated with similar outcomes, as compared with CABG. However, rates of repeat revascularization were significantly higher among patients receiving DES. A large multicenter randomized comparison with longer-term follow-up of 5 or 10 years will likely provide more evidence of the long-term safety, durability, and efficacy of PCI with DES in comparison to CABG.

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

Keywords: Registries, Coronary Artery Disease, Myocardial Infarction, Stroke, Follow-Up Studies, Drug-Eluting Stents, Ventricular Function, Coronary Artery Bypass, Diabetes Mellitus, Percutaneous Coronary Intervention


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