CABG vs. DES Implant for Left Main or Multivessel CAD
What are the long-term outcomes after coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in patients with left main or multivessel coronary artery disease (CAD)?
Data were pooled from the BEST, PRECOMBAT, and SYNTAX trials. The primary outcome was a composite of all-cause death, myocardial infarction, or stroke. The stratified Cox proportional hazards model was used to analyze the impact of revascularization strategy on clinical outcomes, and to determine whether merging of the data from three trials would influence the primary outcome.
The median follow-up was 60 months, and follow-up was completed for 96.2% of patients. The rate of primary outcome was significantly lower with CABG than with PCI (13.0% vs. 16.0%; hazard ratio [HR], 0.83; 95% confidence interval [CI], 0.69-1.00; p = 0.046). The difference was mainly driven by reduction in myocardial infarction (HR, 0.46; 95% CI, 0.33- 0.64; p < 0.001). There was significant interaction between treatment effect and types of CAD, showing CABG to be superior compared to PCI with DES in patients with multivessel CAD (p = 0.001), but no between-group difference in those with left main CAD (p = 0.427). The rates for all-cause death and stroke were similar between the two groups. In contrast, the need for repeat revascularization was significantly lower in the CABG group compared with the PCI group.
The authors concluded that CABG, as compared to PCI with DES, reduced long-term rates of the composite of all-cause death, myocardial infarction, or stroke in patients with left main or multivessel CAD.
This study reports that CABG, as compared to PCI with DES, significantly reduced the risk of all-cause death, myocardial infarction, or stroke in patients with left main or multivessel CAD. The advantage of CABG over PCI with DES was consistent in most major clinical subgroups, and it continued to accrue over time. These findings support the current recommendation that CABG is the better option for patients with severe CAD. A multidisciplinary heart team approach to patients with left main or multivessel CAD is strongly recommended.
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