Surgery vs. Stents for Nondiabetic Multivessel Disease

Study Questions:

What is the effect of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) with drug-eluting stents (DES) on long-term mortality in nondiabetic patients with multivessel coronary artery disease (CAD)?

Methods:

The investigators performed a patient-level meta-analysis to compare the effect of CABG versus PCI with DES on long-term mortality in 1,275 nondiabetic patients with multivessel CAD. Individual patient data from the SYNTAX and BEST trials were pooled. The primary outcome was death from any cause. Stratified Cox proportional hazards models were used to analyze the impact of revascularization strategy on clinical outcomes, and to determine whether or not the merged data from each trial would influence the primary outcome.

Results:

The median follow-up time was 61 months (interquartile range, 50-62 months). The risk of death from any cause was significantly lower in the CABG group than in the PCI group (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.43-0.98; p = 0.039). A similar finding was observed for the risk of death from cardiac causes. The superiority of CABG over PCI was consistent across the major clinical subgroups. Likewise, the rate of myocardial infarction was remarkably lower after CABG than after PCI (HR, 0.40; 95% CI, 0.24-0.65; p < 0.001). However, the rate of stroke was not different between the two groups (HR, 1.13; 95% CI, 0.59-2.17; p = 0.714). The need for repeat revascularization was significantly lower in the CABG group than in the PCI group (HR, 0.55; 95% CI, 0.40-0.75; p < 0.001).

Conclusions:

The authors concluded that CABG, as compared with PCI with DES, significantly reduced the long-term risk of mortality in nondiabetic patients with multivessel CAD.

Perspective:

This study reports that among nondiabetic patients with multivessel CAD, those who received CABG had a lower rate of death from any cause than those who underwent PCI with DES. Furthermore, the rate of myocardial infarction was remarkably lower after CABG than after PCI with DES. These benefits on both the primary outcome and myocardial infarction were consistent across all major clinical subgroups. In contrast, the risk of stroke linked to CABG was relatively small. These data further reinforce the importance of multidisciplinary team decision making for optimal revascularization strategy for patients with multivessel CAD with or without diabetes.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease

Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Drug-Eluting Stents, Mortality, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Primary Prevention, Stents, Stroke


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