Comparative Effectiveness of Revascularization Strategies

Study Questions:

What are the rates of long-term survival after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)?

Methods:

The investigators linked the American College of Cardiology Foundation National Cardiovascular Data Registry and the Society of Thoracic Surgeons Adult Cardiac Surgery Database to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008. Outcomes were compared with the use of propensity scores and inverse-probability-weighting adjustment to reduce treatment selection bias.

Results:

Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence interval [CI], 0.90-1.00). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76-0.82). Similar results were noted in multiple subgroups and with the use of several different analytic methods. Residual confounding was assessed by means of a sensitivity analysis.

Conclusions:

The authors concluded that among older patients with multivessel coronary disease, there was a long-term survival advantage among patients who underwent CABG, as compared with patients who underwent PCI.

Perspective:

This observational study suggests that among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG, as compared with patients who underwent PCI. In the context of the results of randomized trials, a difference in mortality between PCI and CABG may be expected among patients with complex disease, but was not expected among patients with a lesser atherosclerotic burden. Clinicians should note that due to the observational nature of the study, differences in unrecorded selection factors that relate to prognosis, rather than an intrinsic mortality benefit from CABG, may explain why the results in lower-risk patients in the study are not consistent with the results from randomized trials.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Odds Ratio, Myocardial Infarction, Propensity Score, Medicaid, Coronary Disease, Centers for Medicare and Medicaid Services (U.S.), Cost of Illness, Percutaneous Coronary Intervention, Prognosis, Registries, Confidence Intervals, Medicare, Cardiac Surgical Procedures, United States, Emergency Treatment


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