The BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease) trial was designed to compare the cardiovascular outcomes in patients with multivessel coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI) with everolimus-eluting stents versus coronary artery bypass grafting (CABG) in 27 centers in East Asia.¹ Patients with left main disease were excluded from the trial. Because of slow recruitment, the study was terminated early after randomizing 438 patients to PCI and 442 patients to CABG. At 2 years, PCI was not noninferior to CABG in terms of the primary endpoint (a composite of death, myocardial infarction [MI], or target-vessel revascularization) and was inferior to CABG at longer follow-up (median of 4.6 years). As a result of a higher revascularization rate in the PCI groups than in the CABG groups, the primary endpoint for PCI was significantly different from that of CABG. There were no significant differences in mortality rates between the PCI and CABG groups.

The BEST Extended Follow-Up Study compared the outcomes of PCI and CABG over a longer period.² Unlike previous trials,³ no statistically significant differences were found in primary endpoint incidence between the PCI and CABG groups over a median follow-up of 11.8 years. In part, this finding can be explained by advances in PCI procedures, such as the advent of second-generation everolimus-eluting stents and increased intravascular ultrasound usage. Conversely, spontaneous MIs and repeat revascularizations were higher in the PCI group, perhaps because of a lower rate of complete revascularization than in the CABG group.

The mortality benefit of CABG versus PCI in patients with multivessel CAD requires further study with a larger sample size and higher statistical power. Until then, a Heart Team approach is recommended to discuss revascularization options for each patient individually.

References

1. Park SJ, Ahn JM, Kim YH, et al.; BEST Trial Investigators. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med 2015;372:1204-12.
2. Ahn JM, Kang DY, Yun SC, et al.; BEST Extended Follow-Up Study Investigators. Everolimus-eluting stents or bypass surgery for multivessel coronary artery disease: extended follow-up outcomes of multicenter randomized controlled BEST trial. Circulation 2022;146:1581-90.
3. Thuijs DJFM, Kappetein AP, Serruys PW, et al.; SYNTAX Extended Survival Investigators. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial. Lancet 2019;394:1325-34.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging, Echocardiography/Ultrasound, Acute Coronary Syndromes, Stable Ischemic Heart Disease

Keywords: Transcatheter Cardiovascular Therapeutics, TCT22, Coronary Artery Disease, Everolimus, Drug-Eluting Stents, Coronary Artery Bypass, Myocardial Infarction, Stents, Ultrasonography, Interventional

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