Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease

Hannan, Edward L.; Wu, Chuntao; Walford, Gary; Culliford, Alfred T.; Gold, Jeffrey P.; Smith, Craig R.; Higgins, Robert; Carlson, Russell E.; Jones, Robert H.

doi:10.1056/nejmoa071804

Cited by 457 publications

(168 citation statements)

References 27 publications

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“…The findings of these studies are consistent with ours because the relative outcomes associated with the two procedures were similar across quartiles [1] or quintiles [17] of PS or terciles of EuroSCORE and SYNTAX Score [4] . The categorization adopted in these studies may, however, have been too broad to unveil the heterogeneity of treatment-effect estimates [18,19] , while the one adopted here should yield stronger evidence.…”

Section: Discussionsupporting

confidence: 87%

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Description of a methodological approach to verify the outcome-optimization of tailored therapeutic choices and test application to PCI vs. CABG.

Bartolomeo

Guastaroba

Fortuna

et al. 2012

JHA

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Background: The scientific evidence guiding the choice between Percutaneous Coronary Intervention (PCI) and Bypass Graft Surgery (CABG) is inconclusive. Yet, tailoring the choice to the patients' characteristics is generally considered important to optimize outcomes. Objectives:To verify the supposed outcome benefits of tailoring the choice of the revascularization procedure. Methods:We calculated a propensity score (PS) -i.e. the probability, given the patients' characteristics, of undergoing one of the two alternative procedures -for the 11,750 patients with severe coronary disease who underwent coronary revascularization between 2002 and 2008 in an Italian region. Then we investigated the effect-modification of the PS on the Hazard Ratios (HR) of PCI vs. CABG for death, myocardial infarction, stroke and repeat revascularization with a likelihood ratio test and by visual inspection. Results:Only the least important outcome (repeat revascularization) significantly differed across deciles of PS (p=0.05) and its graphical trend supported a favorable effect of the decision process. Conclusions:In agreement with the current scientific uncertainty, but contrary to common opinion, the medical decision process between PCI and CABG based on demographic and clinical factors is marginally capable of optimizing the post-procedural outcomes. The study relies on the assumption that the variables considered by clinicians were among those included in the PS.

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Section: Discussionsupporting

confidence: 87%

“…In the case of severe Coronary Artery Disease (CAD) (left main or multivessel involvement) -the scientific evidence [1][2][3][4][5][6][7][8][9] supporting the interventional choice between Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft (CABG) is inconclusive. Uncertainty surrounds not only the 'best' technique in absolute terms (i.e.…”

mentioning

confidence: 99%

Description of a methodological approach to verify the outcome-optimization of tailored therapeutic choices and test application to PCI vs. CABG.

Bartolomeo

Guastaroba

Fortuna

et al. 2012

JHA

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“…CABG might be more beneficial than PCI in octogenarians regardless of sex. 24,25 Third, because more patients underwent PCI in the later cohort, the followup duration was longer in the CABG group than in the PCI group. The risk of PCI relative to CABG might be different according to the follow-up duration after the index procedure.…”

mentioning

confidence: 99%

Effects of Age and Sex on Clinical Outcomes After Percutaneous Coronary Intervention Relative to Coronary Artery Bypass Grafting in Patients With Triple-Vessel Coronary Artery Disease

et al. 2016

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P revious randomized, controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in the era of balloon angioplasty and bare metal stents (BMS) have generally suggested similar long-term survival up to 5 years in patients with multivessel coronary artery disease (CAD). [1][2][3][4][5][6][7][8][9] However, the subsequent trials in the era of drug-eluting stents (DES), in which mostly high-risk patients with diabetes mellitus or triple-vessel CAD were enrolled, have demonstrated significantly lower mortality after CABG compared with PCI. [10][11][12][13] We also have reported the better long-term outcomes in terms of all-cause death and myocardial infarction (MI) after CABG than after PCI in the all-comer CREDO-Kyoto (Coronary Revascularization Demonstrating Outcome Study in Kyoto) registry Cohort-1 and Cohort-2 in the era of BMS and DES, respectively. 14,15 Clinical Perspective on p 1891Among those factors influencing the decision making on the choice of coronary revascularization strategies (PCI/ Background-Age and sex are important considerations in the choice between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in daily clinical practice. Methods and Results-Of 25 816 patients enrolled in the multicenter Coronary Revascularization Demonstrating OutcomeStudy in Kyoto (CREDO-Kyoto; Cohort-1, n=9877; Cohort-2, n=15 939), the present study population consisted of 5651 patients (men, n=3998; women, n=1653) with triple-vessel coronary artery disease who were considered to be pertinent in comparisons of PCI with CABG (PCI, n=3165; CABG, n=2486). Patients were divided into 3 groups according to the tertiles of age: ≤65 years (n=1972), 66 to 73 years (n=1820), and ≥74 years (n=1859). The excess adjusted mortality risk of PCI relative to CABG was significant in patients ≥74 years of age (hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.10-1.79; P=0.006), whereas the risks were neutral in patients ≤65 years of age (HR, 1.05; 95% CI, 0.73-1.53; P=0.78) and in patients 66 to 73 years of age (HR, 1.03; 95% CI, 0.78-1.36; P=0.85; interaction P=0.003). The excess mortality risk of PCI relative to CABG was significant in men (HR, 1.24; 95% CI, 1.03-1.50; P=0.02) and trended to be significant in women (HR, 1.34; 95% CI, 0.98-1.84; P=0.07) without significant interaction between sex and the mortality risk of PCI relative to CABG (interaction P=0.40). Conclusions-There was a significant association between age and the mortality risk of PCI relative to CABG with excess risk in patients ≥74 years of age and neutral risk in younger patients. There was no significant sex-related difference in the mortality risk of PCI relative to CABG. Correspondence to Takeshi Kimura, MD, Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507 Japan. E-mail taketaka@kuhp.kyoto-ua.ac.jp superelder patients. Furthermore, the 10 RCTs included in the pooled analysis...

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“…In most clinical trials comparing PCI and CABG for the treatment of ULMCA disease, patients with severe left ventricular dysfunction were excluded, 11,12 and several registry studies and randomized trials showed conflicting clinical outcomes of PCI, CABG, or medication for patients with decreased systolic function. [27][28][29] Subsequent randomized trials will be critically important for the development of optimal treatment strategies for patients with CAD, heart failure, and severe left ventricular systolic dysfunction.…”

Section: Discussionmentioning

confidence: 99%

Differential Event Rates and Independent Predictors of Long-Term Major Cardiovascular Events and Death in 5795 Patients With Unprotected Left Main Coronary Artery Disease Treated With Stents, Bypass Surgery, or Medication

Kang¹,

Ahn²,

Lee³

et al. 2017

Circ: Cardiovascular Interventions

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P atients with unprotected left main coronary artery (ULMCA) disease are considered at highest-risk of adverse cardiovascular events and mortality within the broad range of risk for patients with obstructive coronary artery disease (CAD). On the basis of several clinical and anatomic characteristics and patient/physician preference, individual patients with ULMCA disease might be treated with percutaneous coronary intervention (PCI), coronary-artery bypass grafting (CABG), or medication alone.1 Depending on the specific index treatment strategy, accurate knowledge of the key determinants of adverse cardiovascular events and mortality would be extremely useful for clinical and investigational purposes. To date, several scoring systems have been developed for risk stratification and decision making of optimum revascularization strategy in patients with complex CAD with or without ULMCA disease.2-5 However, easy application of these scoring systems in clinical practice might be hampered because of limited clinical performance and complexities. In particular, Background-Identifying predictive factors for major cardiovascular events and death in patients with unprotected left main coronary artery disease is of great clinical value for risk stratification and possible guidance for tailored preventive strategies. Methods and Results-The Interventional Research Incorporation Society-Left MAIN Revascularization registry included 5795 patients with unprotected left main coronary artery disease (percutaneous coronary intervention, n=2850; coronaryartery bypass grafting, n=2337; medication alone, n=608). We analyzed the incidence and independent predictors of major adverse cardiac and cerebrovascular events (MACCE; a composite of death, MI, stroke, or repeat revascularization) and all-cause mortality in each treatment stratum. During follow-up (median, 4.3 years), the rates of MACCE and death were substantially higher in the medical group than in the percutaneous coronary intervention and coronary-artery bypass grafting groups (P<0.001). In the percutaneous coronary intervention group, the 3 strongest predictors for MACCE were chronic renal failure, old age (≥65 years), and previous heart failure; those for all-cause mortality were chronic renal failure, old age, and low ejection fraction. In the coronary-artery bypass grafting group, old age, chronic renal failure, and low ejection fraction were the 3 strongest predictors of MACCE and death. In the medication group, old age, low ejection fraction, and diabetes mellitus were the 3 strongest predictors of MACCE and death. Conclusions-Among patients with unprotected left main coronary artery disease, the key clinical predictors for MACCE and death were generally similar regardless of index treatment. This study provides effect estimates for clinically relevant predictors of long-term clinical outcomes in real-world left main coronary artery patients, providing possible guidance for tailored preventive strategies. Clinical Trial Registration-URL: https://clinicaltrials.gov. Un...

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Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease

Abstract: For patients with multivessel disease, CABG continues to be associated with lower mortality rates than does treatment with drug-eluting stents and is also associated with lower rates of death or myocardial infarction and repeat revascularization.

Cited by 457 publications

References 27 publications

Description of a methodological approach to verify the outcome-optimization of tailored therapeutic choices and test application to PCI vs. CABG.

Description of a methodological approach to verify the outcome-optimization of tailored therapeutic choices and test application to PCI vs. CABG.

Effects of Age and Sex on Clinical Outcomes After Percutaneous Coronary Intervention Relative to Coronary Artery Bypass Grafting in Patients With Triple-Vessel Coronary Artery Disease

Differential Event Rates and Independent Predictors of Long-Term Major Cardiovascular Events and Death in 5795 Patients With Unprotected Left Main Coronary Artery Disease Treated With Stents, Bypass Surgery, or Medication

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