Everolimus-Eluting Stents or CABG for LV Systolic Dysfunction
What is the comparative effectiveness of coronary artery bypass grafting (CABG) when compared with percutaneous coronary intervention (PCI) in patients with severe left ventricular (LV) systolic dysfunction?
Patients with multivessel disease and severe LV systolic dysfunction (ejection fraction ≤35%) who underwent either PCI with everolimus-eluting stent (EES) or CABG were selected from the New York State registries. The primary outcome was long-term all-cause death. Secondary outcomes were individual outcomes of myocardial infarction (MI), stroke, and repeat revascularization. The risks of outcomes were analyzed in the matched cohort using a Cox proportional regression model after stratifying on the matched pairs.
Among the 4,616 patients who fulfilled the inclusion criteria (1,351 EES and 3,265 CABG), propensity score matching identified 2,126 patients with similar propensity scores. At short-term follow-up, PCI was associated with a lower risk of stroke (hazard ratio [HR], 0.05; 95% confidence interval [CI], 0.01-0.39; p = 0.004) when compared with CABG. At long-term follow-up (median 2.9 years), PCI was associated with a similar risk of death (HR, 1.01; 95% CI, 0.81-1.28; p = 0.91), a higher risk of MI (HR, 2.16; 95% CI, 1.42-3.28; p = 0.0003), a lower risk of stroke (HR, 0.57; 95% CI, 0.33-0.97; p = 0.04), and a higher risk of repeat revascularization (HR, 2.54; 95% CI, 1.88-3.44; p < 0.0001). The test for interaction was significant (p = 0.002) for completeness of revascularization, such that in patients where complete revascularization was achieved with PCI, there was no difference in MI between PCI and CABG.
The authors concluded that among patients with multivessel disease and severe LV systolic dysfunction, PCI with EES had comparable long-term survival when compared with CABG.
This registry study reports that in patients with multivessel disease and severe LV systolic dysfunction, PCI with an EES resulted in similar survival as that of CABG. While CABG was associated with higher upfront risk of stroke, PCI was associated with higher long-term risk of repeat revascularization and perhaps MI (in those with incomplete revascularization). PCI with current-generation drug-eluting stents appears to be an acceptable alternative to CABG in selected patients with LV dysfunction, where complete revascularization is possible. Additional prospective clinical trials are indicated to confirm these findings.
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