Stroke Rates Following CABG vs. PCI

Study Questions:

Is there a difference in stroke rate after coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI)?

Methods:

Patient-level data were pooled from 11 randomized clinical trials of CABG versus PCI using stents (not balloon angioplasty) in patients with multivessel or left main coronary disease. The 30-day and 5-year stroke rates for the CABG patients were compared to those of the PCI patients.

Results:

Data from 11,518 (5,765 CABG, 5,753 PCI) patients were pooled; 293 strokes and 976 deaths occurred. The mean follow-up was 3.8 ± 1.4 years. The 30-day stroke rate was higher in the CABG group than the PCI group (1.1% compared to 0.4%; hazard ratio [HR] for PCI, 0.33; 95% CI, 0.20-0.53). The cumulative 5-year stroke rate was also higher in the CABG group than in the PCI group (3.2% vs. 2.6%; HR for PCI, 0.77; 95% CI, 0.61-0.97). The stroke rate between 31 days and 5 years was comparable between PCI and CABG (p = 0.72). Patients with stroke within 30 days had significantly higher 5-year mortality than those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and after CABG (41.5% vs. 8.9%, p < 0.001).

Conclusions:

CABG was associated with a higher 5-year stroke rate than PCI, primarily because of an increased 30-day stroke rate. For both the CABG and PCI groups, 5-year mortality was notably higher in those with a stroke within 30 days compared to those without.

Perspective:

Stroke is a rare, but feared complication of CABG and PCI. This pooled analysis of patient-level data found a higher 30-day stroke rate in patients who underwent CABG compared to those who underwent PCI. The higher stroke rate in CABG patients is likely multifactorial and related to intraprocedural aortic clamping and manipulation; hypercoagulable medications used to treat postoperative bleeding; perioperative atrial fibrillation; and intraoperative cerebral hypoperfusion. Not surprisingly, patients with stroke within 30 days of their procedure are at higher risk of dying within 5 years than those without stroke. The magnitude of this risk is notable, however, with the 5-year mortality rate for 30-day stroke patients in both the CABG and PCI groups surpassing 40%.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease

Keywords: Atrial Fibrillation, Constriction, Coronary Artery Bypass, Coronary Artery Disease, Myocardial Revascularization, Percutaneous Coronary Intervention, Stents, Stroke, Vascular Diseases


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