Percutaneous versus surgical revascularization for multivessel coronary artery disease: A single center 10 year follow-up of SOS trial patients

Percutaneous coronary intervention versus coronary artery by-pass grafting in premature coronary artery disease: What is the evidence? -A narrative review

Coronary artery disease (CAD) remains one of the leading causes of death globally. In the United States of America, in 2016, 19% of all patients under the age of 65 died of cardiovascular disease despite improvements in primary prevention. The premature clinical onset of symptoms in the young population (<60 years) is much more aggressive than in the older population, and the overall long-term prognosis is poor. CAD appears to have a rapidly progressive form in those under the age of 60 due to genetic predisposition, smoking, and substance abuse, however, the ideal management strategy is still yet to be established. The two primary methods of establishing coronary revascularization are percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Despite the increasing prevalence of CAD in the young population, they are consistently underrepresented in major randomized clinical trials of each revascularization strategy. Both CABG and PCI are known to have similar survival rates, but PCI is associated with higher repeat revascularization rate. Many argue this may be due to the progressive nature of CAD combined with the vessel patency time required in a patient under 60 with potentially another 20-30 years of life. There is little in literature regarding the outcomes of these various revascularization strategies in populations under 60 years with CAD. This review summarises the current evidence for each revascularisation strategy in patients under the age of 60 and suggests future avenues of research for this unique age group.

Ten-year outcomes after percutaneous coronary intervention versus coronary artery bypass grafting for multivessel or left main coronary artery disease: a systematic review and meta-analysis

BACKGROUND

Short-term and long-term comparative outcomes after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for multivessel coronary artery (MVCA) or left main coronary artery (LMCA) disease are highly debated.

GOALS

We performed a meta-analysis to evaluate the difference between PCI and CABG for the treatment of patients with MVCA or LMCA in long-term follow-up.

METHODS

Literatures were searched in PubMed, EMBASE and The Cochrane Library from January 1, 2000 to January 1, 2021, including RCTs and observational studies (OSs). The primary outcome was all-cause mortality at 10 years follow-up, and the secondary outcomes included cardiac mortality, repeated revascularization, myocardial infarction, and stroke.

RESULTS

A total of 5 RCTs reporting data from 3013 participants and 4 OSs of 5608 participants were included for analysis. There was no significant difference between PCI and CABG in all-cause mortality (Odds Ratio (OR) 1.03 [95% confidence interval (CI) 0.89 to 1.19]), whereas PCI was associated with higher cardiac mortality (OR 0.76 [95% CI 0.65 to 0.90]) and repeated revascularization rate comparing to CABG (OR 1.77 [95% CI 1.08 to 2.89]; I² = 94.61%). The difference between PCI and CABG in repeated revascularization in either RCTs or OSs, in myocardial infarction in either RCTs or OSs were not significant. In OSs, stroke rate in PCI group was lower than those in CABG, but not in RCTs. There was a significant increase of stroke rate in CABG comparing to PCI (OR 0.65 [95% CI 0.53 to 0.80]; I² = 0.00%). No significant difference between PCI and CABG in myocardial infarction was not observed (OR 0.92 [95% CI 0.64 to 1.31]; I² = 57.84%).

CONCLUSION

Evidence from our study and prior studies suggested the superiority of CABG over PCI in improving 5- but not 10-year survival among patients with MVCA. In the contrast, there was no significant difference between CABG and PCI for treating patients with LMCA in either 5- or 10-year survival rate. More long-term trials are needed to better define differences of outcome between 2 techniques.

Sex- and ethnic group-specific nationwide trends in the use of coronary artery bypass grafting in the United States

OBJECTIVE

This study examined nationwide trends in use of coronary artery bypass grafting between 1988 and 2004.

METHODS

The Nationwide Inpatient Sample database was used to calculate age-adjusted rate of coronary artery bypass grafting from 1988 to 2004. Specific International Classification of Diseases, Ninth Revision, Clinical Modification codes for coronary artery bypass grafting were used to compile data. Patient demographic data were also analyzed.

RESULTS

The database recorded 1,145,285 patients older than 40 years who underwent coronary artery bypass grafting from 1988 to 2004. Mean age was 60.21 +/- 10.55 years. Male patients underwent coronary artery bypass grafting more than twice as frequently as female patients (70.6% vs 29.4%). From 1988, total age-adjusted rate gradually increased for 10 years until 1997 (79.29 per 100,000 with 95% confidence interval 70.88-87.71 per 100,000 in 1988, 131.31 per 100,000 with 95% confidence interval 119.02-143.59 per 100,000 in 1997, P < .01), with ensuing rapid decline to nearly the lowest level at end of study in 2004 (83.01 per 100,000 with 95% confidence interval 75.68-90.33 per 100,000, P < .01). Although trends were similar across ethnicity and sex, female and ethnic minority patients had lower rates of bypass surgery than did male and white patients.

CONCLUSIONS

Use of coronary artery bypass grafting has decreased dramatically in recent years, with even lower use among female and ethnic minority patients. This decline may be related to significant advances in percutaneous coronary interventions and improved medical treatment of atherosclerosis in the past 10 years.