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Long-Term Mortality in Ischemic HF Patients With PCI vs. CABG
Quick Takes
- In a large propensity-matched analysis of a retrospective registry, HF patients with ischemic cardiomyopathy (ICM) revascularized with CABG had a lower mortality rate compared to PCI (OR, 0.62; 95% CI, 0.41-0.96).
- This benefit with CABG was notable in the long-term after 4 years of follow-up and translated to a mean event-free survival of 0.59 years more compared to PCI.
- There was a wide site-level variation in choice of revascularization strategy for HF patients with ICM.
Study Questions:
What is the long-term mortality in heart failure (HF) patients with ischemic cardiomyopathy (ICM) revascularized with coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI)?
Methods:
This was a retrospective analysis of all patients in Sweden who underwent a coronary angiography with a primary diagnosis of HF from 2000-2018. Patients with a diagnosis of acute coronary syndrome within the 6 months prior were excluded. All patients were enrolled in the SCAAR registry that captures granular details about demographic, clinical, and angiographic characteristics. The primary endpoint was time to all-cause mortality and analyses were performed using propensity matching.
Results:
A total of 2,509 patients were included in the study cohort comprised of 82.9% men. Mean age was 68.1 ± 9.4 years, 35.8% had diabetes, 34.7% had prior history of myocardial infarction, and 64.9% had three-vessel or left main disease. PCI was performed in 56.2% and CABG in 43.8%. Patients receiving PCI were older, with a higher comorbidity burden and higher prevalence of prior CABG or PCI. Most patients received drug-eluting stents. Those receiving CABG were more likely to have left main disease. Between 2000-2008, CABG was the preferred method, replaced by PCI subsequently. There was a wide site-level variation in revascularization strategy. Another 1,150 patients with multivessel disease were not revascularized and only treated medically. Over a median follow-up duration of 3.9 years, CABG was associated with a lower risk of death compared to PCI (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.41-0.96). This mortality benefit was notable after 4 years of follow-up. Mean event-free survival was 0.59 years longer with CABG than after PCI. There was a significant effect modification between diabetes and CABG. When hospitals were divided into quintiles based on increasing proportion of ICM patients receiving PCI, risk of death increased linearly with increasing quintiles.
Conclusions:
In a large, retrospective registry-based analysis of patients with ICM, revascularization with CABG was associated with a lower mortality. However, this mortality benefit was noted over the long-term after 3 years of revascularization.
Perspective:
The appropriate strategy for revascularizing HF patients with ICM is a heavily debated topic. The STITCH trial showed a benefit with CABG compared to optimal medical therapy in HF patients with ICM and reduced ejection fraction. However, there are no trials comparing PCI to CABG in this population.
While this study showed that CABG had a long-term survival benefit compared to PCI in HF patients with ICM, the benefit was apparent after 4 years of follow-up and translated to a mean event-free survival increment of 0.59 years with CABG. While these results parallel findings from the STITCH trial highlighting superiority of CABG, interpretation is limited by the fact that this was a retrospective study. Although propensity matching was used, it is difficult to match for unmeasured confounders that may influence a clinician’s decision making regarding choice of revascularization strategy. It also highlights that when debating optimal revascularization strategies for a HF patient with ICM, long-term prognosis and higher upfront risk with CABG are considered.
Other noteworthy findings include that a large proportion of ICM patients with HF continue to be managed medically without revascularization. There was also a very large site-level variation in choice of revascularization strategy—highlighting the fact that regardless of a patient’s characteristics, decisions are still driven by physician preferences due to lack of high-quality evidence addressing this important question.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Angioplasty, Cardiac Surgical Procedures, Cardiomyopathies, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Drug-Eluting Stents, Heart Failure, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention
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