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PCI With DES vs. CABG in Left Main CAD: Meta-Analysis
Quick Takes
- Among patients with left main CAD, there was no statistically significant difference in 5-year all-cause deaths between PCI with DES and CABG, while a Bayesian approach suggested that a difference favoring CABG probably exists, which is likely <0.2% per year.
- Of note, patients treated with PCI had higher rates of spontaneous MI and repeat revascularization over the 5 years than did patients treated with CABG.
- Based on these and other available data, a multidisciplinary heart team approach to communicate expected outcome differences would be optimal to assist patients in choosing a particular treatment strategy.
Study Questions:
What are the long-term outcomes for patients with left main coronary artery disease (CAD) treated with percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass grafting (CABG)?
Methods:
The investigators searched MEDLINE, Embase, and the Cochrane database using the search terms “left main,” “percutaneous coronary intervention” or “stent,” and “coronary artery bypass graft” to identify randomized controlled trials (RCTs) published in English between database inception and August 31, 2021, comparing PCI with DES with CABG in patients with left main CAD that had ≥5 years of patient follow-up for all-cause mortality for this individual patient data meta-analysis. Two authors (MSS and BAB) identified studies meeting the criteria. The primary endpoint was 5-year all-cause mortality. Secondary endpoints were cardiovascular death, spontaneous myocardial infarction (MI), procedural MI, stroke, and repeat revascularization. The authors used a one-stage approach; event rates were calculated by use of the Kaplan-Meier method and treatment group comparisons were made by use of a Cox frailty model, with trial as a random effect. In Bayesian analyses, the probabilities of absolute risk differences in the primary endpoint between PCI and CABG being >0.0%, and ≥1.0%, 2.5%, or 5.0%, were calculated.
Results:
The literature search yielded 1,599 results, of which four RCTs—SYNTAX, PRECOMBAT, NOBLE, and EXCEL—meeting inclusion criteria were included in the meta-analysis. A total of 4,394 patients, with a median SYNTAX score of 25.0 (interquartile range, 18.0–31.0), were randomly assigned to PCI (n = 2,197) or CABG (n = 2,197). The Kaplan-Meier estimate of 5-year all-cause death was 11.2% (95% confidence interval [CI], 9.9–12.6) with PCI and 10.2% (95% CI, 9.0–11.6) with CABG (hazard ratio [HR], 1.10; 95% CI, 0.91–1.32; p = 0.33), resulting in a nonstatistically significant absolute risk difference of 0.9% (95% CI, −0.9 to 2.8). In Bayesian analyses, there was an 85.7% probability that death at 5 years was greater with PCI than with CABG; this difference was more likely than not <1.0% (<0.2% per year). The numerical difference in mortality was comprised more of noncardiovascular than cardiovascular death. Spontaneous MI (6.2%, 95% CI 5.2–7.3 vs. 2.6%, 95% CI 2.0–3.4; hazard ratio [HR] 2.35, 95% CI 1.71–3.23; p < 0.0001) and repeat revascularization (18.3%, 95% CI 16.7–20.0 vs. 10.7%, 95% CI 9.4–12.1; HR 1.78, 95% CI 1.51–2.10; p < 0.0001) were more common with PCI than with CABG. Differences in procedural MI between strategies depended on the definition used. Overall, there was no difference in the risk of stroke between PCI (2.7%, 95% CI 2.0–3.5) and CABG (3.1%, 95% CI 2.4–3.9; HR 0.84, 95% CI 0.59–1.21; p = 0.36), but the risk was lower with PCI in the first year after randomization (HR, 0.37; 95% CI, 0.19–0.69).
Conclusions:
The authors concluded that among patients with left main CAD and, largely, low or intermediate coronary anatomical complexity, there was no statistically significant difference in 5-year all-cause death between PCI and CABG.
Perspective:
This individual patient data meta-analysis reports that among patients with left main CAD, there was no statistically significant difference in 5-year all-cause deaths between those treated with PCI with DES and those treated with CABG, while a Bayesian approach suggested that a difference favoring CABG probably exists, which is more likely than not <0.2% per year. Of note, patients treated with PCI had higher rates of spontaneous MI and repeat revascularization over the 5 years than did patients treated with CABG. Based on these and other available data, a multidisciplinary heart team approach to communicate expected outcome differences would be optimal to assist patients in choosing a particular treatment strategy.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias
Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Drug-Eluting Stents, Frailty, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Outcome Assessment, Health Care, Percutaneous Coronary Intervention, Secondary Prevention, Stroke
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