Long-Term Safety and Efficacy of Percutaneous Coronary Intervention With Stenting and Coronary Artery Bypass Surgery for Multivessel Coronary Artery Disease

Abstract

Background-Randomized trials that studied clinical outcomes after percutaneous coronary intervention (PCI) with bare metal stenting versus coronary artery bypass grafting (CABG) are underpowered to properly assess safety end points like death, stroke, and myocardial infarction. Pooling data from randomized controlled trials increases the statistical power and allows better assessment of the treatment effect in high-risk subgroups. Methods and Results-We performed a pooled analysis of 3051 patients in 4 randomized trials evaluating the relative safety and efficacy of PCI with stenting and CABG at 5 years for the treatment of multivessel coronary artery disease. The primary end point was the composite end point of death, stroke, or myocardial infarction. The secondary end point was the occurrence of major adverse cardiac and cerebrovascular accidents, death, stroke, myocardial infarction, and repeat revascularization. We tested for heterogeneities in treatment effect in patient subgroups. At 5 years, the cumulative incidence of death, myocardial infarction, and stroke was similar in patients randomized to PCI with stenting versus CABG (16.7% versus 16.9%, respectively; hazard ratio, 1.04, 95% confidence interval, 0.86 to 1.27; Pϭ0.69).Repeat revascularization, however, occurred significantly more frequently after PCI than CABG (29.0% versus 7.9%, respectively; hazard ratio, 0.23; 95% confidence interval, 0.18 to 0.29; PϽ0.001). Major adverse cardiac and cerebrovascular events were significantly higher in the PCI than the CABG group (39.2% versus 23.0%, respectively; hazard ratio, 0.53; 95% confidence interval, 0.45 to 0.61; PϽ0.001). No heterogeneity of treatment effect was found in the subgroups, including diabetic patients and those presenting with 3-vessel disease. Conclusions-In this pooled analysis of 4 randomized trials, PCI with stenting was associated with a long-term safety profile similar to that of CABG. However, as a result of persistently lower repeat revascularization rates in the CABG patients, overall major adverse cardiac and cerebrovascular event rates were significantly lower in the CABG group at 5

Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease

“…After 5 years of follow-up, the meta-analysis did not show any significant differences in rates of survival between the CABG and PCI groups, 34 although other studies have shown differences in mortality. [10][11][12] Second, the use of medication differed between the groups in our study, reflecting variations in standard care of patients between the two treatment groups. Third, more patients withdrew, after randomization, from the CABG group than from the PCI group.…”

“…Others have shown a significant long-term survival advantage with surgery (e.g., the Stent or Surgery [SOS] study). [10][11][12] Studies comparing PCI involving drugeluting stents with CABG have generally been smaller and nonrandomized. [13][14][15][16][17][18][19][20][21][22][23][24] Data from randomized, controlled trials of drug-eluting stents as compared with bare-metal stents have shown significant reductions in the rate of repeat intervention, with similar rates of death and myocardial infarction.…”

Prediction of Long-Term Survival in Patients with End-Stage Heart Failure Secondary to Ischemic Heart Disease: Surgical Correction and Volumetric Analysis

“…3) In such situation, the most critical form is called ischemic cardiomyopathy (ICM), which is characterized by poor prognosis despite various treatments. 4,5) Additionally, it was demonstrated that concomitant functional MR is one of the risk factors for long-term survival in ischemic heart disease. 6,7) Thus, ICM with functional MR is the most critical combination and the definitive treatment is heart transplantation.…”

Clinical Outcomes After Drug-Eluting Stents Versus Coronary Artery Bypass Surgery in High Surgical Risk Patients With Left Main or Three-Vessel Coronary Artery Disease

“…11,12 Recent randomized controlled trials have shown that overall major adverse cardiac and cerebrovascular events (MACCE) are lower with CABG than PCI in patients revascularized for unprotected LM-3VD. [13][14][15][16][17][18] However, the outcomes of CABG and PCI were similar in patients who have focal disease with SYNTAX score ≤ 22. 18,19 Due to the more invasive nature and higher shortterm morbidity of CABG, PCI has been empirically considered a good alternative to CABG in patients who are deemed a high surgical risk.…”