Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease - BEST

Sep 19, 2022
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
CardioVascular Research Foundation
Date Presented:
09/19/2022
Date Published:
09/19/2022
Date Updated:
09/19/2022
Original Posted Date:
03/16/2015
References

Contribution To Literature:

Highlighted text has been updated as of September 19, 2022.

The BEST trial showed that long-term adverse cardiovascular events were increased after multivessel PCI with everolimus-eluting stents compared with CABG.

Description:

The goal of the trial was to evaluate treatment with multivessel percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) among patients with coronary artery disease.

Study Design

  • Parallel
  • Randomized
  • Stratified

Patients with multivessel coronary disease were randomized to PCI with everolimus-eluting stents (n = 438) versus CABG (n = 442).

  • Total number of enrollees: 880
  • Duration of follow-up: median 4.6 years
  • Mean patient age: 64 years
  • Percentage female: 31%
  • Percentage with diabetes: 40%

Inclusion criteria:

  • Patients at least 18 years of age with multivessel coronary disease and appropriate for either PCI or CABG

Exclusion criteria:

  • Significant left main disease

Other salient features:

  • Approximately one-third had a chronic total occlusion
  • Mean SYNTAX score: 24
  • Intravascular ultrasound was performed in 72% of the PCI group
  • Off-pump CABG was performed in 64% of the CABG group
  • Complete revascularization: 50.9% of the PCI group vs. 71.5% of the CABG group

Principal Findings:

The study was terminated early in October 2013 due to slow enrollment. At that time, 880 of the planned 1,776 subjects had been enrolled.

The primary outcome of death, myocardial infarction (MI), or target vessel revascularization (TVR) at 2 years occurred in 11.0% of the PCI group versus 7.9% of the CABG group (p = 0.32 for noninferiority), and at 4.6 years, occurred in 15.3% of the PCI group versus 10.6% of the CABG group (p = 0.04). Patients with diabetes appeared to derive more benefit from CABG (p for interaction = 0.06).

Secondary outcomes:

  • Death: 6.6% vs. 5.0% (p = 0.30), respectively, for PCI vs. CABG
  • MI: 4.8% vs. 2.7% (p = 0.11), respectively, for PCI vs. CABG
  • Spontaneous MI: 4.3% vs. 1.6% (p = 0.02), respectively, for PCI vs. CABG
  • TVR: 11.0% vs. 5.4% (p = 0.003), respectively, for PCI vs. CABG
  • Stroke: 2.5% vs. 2.9% (p = 0.72), respectively, for PCI vs. CABG

Long-term extended follow-up (median 11.8 years):

  • Death, MI, or TVR: 34.5% in the PCI group vs. 30.3% in the CABG group (p = 0.26)
  • Death, MI, or stroke: 28.8% in the PCI group vs. 27.1% in the CABG group (p = 0.70)
  • All-cause mortality: 20.5% in the PCI group vs. 19.9% in the CABG group (p = 0.86)
  • Spontaneous MI: 7.1% in the PCI group vs. 3.8% in the CABG group (p = 0.031)
  • Any repeat revascularization: 22.6% in the PCI group vs. 12.7% in the CABG group (p < 0.001)

Interpretation:

Among patients with multivessel coronary disease, PCI was not noninferior to CABG at 2 years and was inferior to CABG with longer follow-up. With long-term extended follow-up, PCI was associated with more spontaneous MI and any repeat revascularization procedure compared with CABG. Long-term mortality was similar between treatment groups. While most previous studies have reported excess strokes with CABG, this study found a similar frequency between groups. These findings apply to individuals of Asian descent.

References:

Ahn JM, Kang DY, Yun SC, et al., on behalf of the 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;Sep 19:[Epub ahead of print].

Presented by Dr. Jung-Min Ahn at the Transcatheter Cardiovascular Therapeutics meeting (TCT 2022), Boston, MA, September 19, 2022.

Park SJ, Ahn JM, Kim YH, et al., on behalf of the BEST Trial Investigators. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med 2015;372:1204-12.

Presented by Dr. Seung-Jung Park at ACC.15, San Diego, CA, March 16, 2015.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: ACC Annual Scientific Session, Cardiac Surgical Procedures, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Disease, Drug-Eluting Stents, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Stents, Stroke, TCT22, Transcatheter Cardiovascular Therapeutics


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