Randomized, controlled trial of coronary artery bypass surgery versus percutaneous coronary intervention in patients with multivessel coronary artery disease: six-year follow-up from the Stent or Surgery Trial (SoS)

The effect of coronary revascularization treatment timing on mortality in patients with stable ischemic heart disease in British Columbia

BACKGROUND

Prior research has shown that patients with stable ischemic heart disease who undergo delayed coronary artery bypass graft (CABG) surgery face higher mortality rates than those who receive CABG within the time recommended by physicians. However, this research did not account for percutaneous coronary intervention (PCI), a widely available alternative to delayed CABG in many settings. We sought to establish whether there was a difference in mortality between timely PCI and delayed CABG.

METHODS

We identified 25,520 patients 60 years or older who underwent first-time non-emergency revascularization for angiographically-proven, stable left main or multi-vessel ischemic heart disease in British Columbia between January 1, 2001, and December 31, 2016. We estimated unadjusted and adjusted mortality after index revascularization or last staged PCI for patients undergoing delayed CABG compared to timely PCI.

FINDINGS

After adjustment with inverse probability of treatment weights, at three years, patients who underwent delayed CABG had a statistically significant lower mortality compared with patients who received timely PCI (4.3% delayed CABG, 13.5% timely PCI; risk ratio 0.32, 95% CI 0.24-0.40).

INTERPRETATION

Patients who undergo CABG with delay have a lower risk of death than patients who undergo PCI within appropriate time. Our results suggest that patients who wish to receive CABG as their revascularization treatment will receive a mortality benefit over PCI as an alternative strategy.

The association of timing of coronary artery bypass grafting for non-ST-elevation myocardial infarction and clinical outcomes in the contemporary United States

BACKGROUND

In contrast to the timing of coronary angiography and percutaneous coronary intervention, the optimal timing of coronary artery bypass grafting (CABG) in non-ST-elevation myocardial infarction (NSTEMI) has not been determined. Therefore, we compared in-hospital outcomes according to different time intervals to CABG surgery in a contemporary NSTEMI population in the USA.

METHODS

We identified all NSTEMI hospitalizations from 2016 to 2020 where revascularization was performed with CABG. We excluded NSTEMI with high-risk features using prespecified criteria. CABG was stratified into ≤24 h, 24-72 h, 72-120 h, and >120 h from admission. Outcomes of interest included in-hospital mortality, perioperative complications, length of stay (LOS), and hospital cost.

RESULTS

A total of 147 170 NSTEMI hospitalizations where CABG was performed were assessed. A greater percentage of females, Blacks, and Hispanics experienced delays to CABG surgery. No difference in in-hospital mortality was observed, but CABG at 72-120 h and at >120 h was associated with higher odds of non-home discharge and acute kidney injury compared with CABG at ≤24 h from admission. In addition to these differences, CABG at >120 h was associated with higher odds of gastrointestinal hemorrhage and need for blood transfusion. All 3 groups with CABG delayed >24 h had longer LOS and hospital-associated costs compared with hospitalizations where CABG was performed at ≤24 h.

CONCLUSION

CABG delays in patients with NSTEMI are more frequently experienced by women and minority populations and are associated with an increased burden of complications and healthcare cost.

Five-year outcomes in patients with multivessel coronary artery disease undergoing surgery or percutaneous intervention

The outcomes from real-life clinical studies regarding the optimal revascularization strategy in patients with multivessel coronary artery disease (MVD) are still poorly investigated. In this retrospective study we assessed 5-year outcomes: primary, secondary endpoints and quality of life of 1035 individuals with severe coronary artery disease (CAD) treated either with coronary artery bypass grafting (CABG)-356 patients or percutaneous coronary intervention (PCI)-679 patients according to the recommendation of a local Heart Team (HT). At 5 years no significant difference in overall mortality and rates of myocardial infarctions (MI) were observed between CABG and PCI cohorts (11.0% vs. 13.4% for PCI, P = 0.27 and 9.6% vs. 12.8% for PCI, P = 0.12, respectively). The incidence of major adverse cardiac and cerebrovascular events (MACCE), mainly driven by increased rates of repeat revascularization (RR) were higher in PCI-cohort than in CABG-group (56.1% vs. 40.4%, P < 0.01 and 26.8% vs. 12.6%, P < 0.01, respectively), while CABG-patients experienced stroke more often (7.3% vs. 3.1% for PCI, P < 0.01). In real-life practice with long-term follow-up, none of the two revascularization modalities implemented following HT decisions showed overwhelming superiority: occurrence of death and MI were similar, rates of RR favoured CABG, while incidence of strokes advocated PCI.

Percutaneous Coronary Intervention vs Coronary Artery Bypass Graft Surgery for Left Main Disease in Patients With and Without Acute Coronary Syndromes: A Pooled Analysis of 4 Randomized Clinical Trials

Importance

Patients with left main coronary artery disease presenting with an acute coronary syndrome (ACS) represent a high-risk and understudied subgroup of patients with atherosclerosis.

Objective

To assess clinical outcomes after PCI vs CABG in patients with left main disease with vs without ACS.

Design, Setting, and Participants

Data were pooled from 4 trials comparing PCI with drug-eluting stents vs CABG in patients with left main disease who were considered equally suitable candidates for either strategy (SYNTAX, PRECOMBAT, NOBLE, and EXCEL). Patients were categorized as presenting with or without ACS. Kaplan-Meier event rates through 5 years and Cox model hazard ratios were generated, and interactions were tested. Patients were enrolled in the individual trials from 2004 through 2015. Individual patient data from the trials were pooled and reconciled from 2020 to 2021, and the analyses pertaining to the ACS subgroup were performed from March 2022 through February 2023.

Main Outcomes and Measures

The primary outcome was death through 5 years. Secondary outcomes included cardiovascular death, spontaneous myocardial infarction (MI), procedural MI, stroke, and repeat revascularization.

Results

Among 4394 patients (median [IQR] age, 66 [59-73] years; 3371 [76.7%] male and 1022 [23.3%] female) randomized to receive PCI or CABG, 1466 (33%) had ACS. Patients with ACS were more likely to have diabetes, prior MI, left ventricular ejection fraction less than 50%, and higher SYNTAX scores. At 30 days, patients with ACS had higher all-cause death (hazard ratio [HR], 3.40; 95% CI, 1.81-6.37; P < .001) and cardiovascular death (HR, 3.21; 95% CI, 1.69-6.08; P < .001) compared with those without ACS. Patients with ACS also had higher rates of spontaneous MI (HR, 1.70; 95% CI, 1.25-2.31; P < .001) through 5 years. The rates of all-cause mortality through 5 years with PCI vs CABG were 10.9% vs 11.5% (HR, 0.93; 95% CI, 0.68-1.27) in patients with ACS and 11.3% vs 9.6% (HR, 1.19; 95% CI, 0.95-1.50) in patients without ACS (P = .22 for interaction). The risk of early stroke was lower with PCI vs CABG (ACS: HR, 0.39; 95% CI, 0.12-1.25; no ACS: HR, 0.35; 95% CI, 0.16-0.75), whereas the 5-year risks of spontaneous MI and repeat revascularization were higher with PCI vs CABG (spontaneous MI: ACS: HR, 1.74; 95% CI, 1.09-2.77; no ACS: HR, 3.03; 95% CI, 1.94-4.72; repeat revascularization: ACS: HR, 1.57; 95% CI, 1.19-2.09; no ACS: HR, 1.90; 95% CI, 1.54-2.33), regardless of ACS status.

Conclusion and Relevance

Among largely stable patients undergoing left main revascularization and with predominantly low to intermediate coronary anatomical complexity, those with ACS had higher rates of early death. Nonetheless, rates of all-cause mortality through 5 years were similar with PCI vs CABG in this high-risk subgroup. The relative advantages and disadvantages of PCI vs CABG in terms of early stroke and long-term spontaneous MI and repeat revascularization were consistent regardless of ACS status.

Trial Registration

ClinicalTrials.gov Identifiers: NCT00114972, NCT00422968, NCT01496651, NCT01205776.

Management of Stable Angina in the Older Adult Population

As society ages, the number of older adults with stable ischemic heart disease continues to rise. Older adults exhibit the greatest morbidity and mortality from stable angina. Furthermore, they suffer a higher burden of comorbidity and adverse events from treatment than younger patients. Given that older adults were excluded or underrepresented in most randomized controlled trials of stable ischemic heart disease, evidence for management is limited and hinges on subgroup analyses of trials and observational studies. This review aims to elucidate the current definitions of aging, assess the overall burden and clinical presentations of stable ischemic heart disease in older patients, weigh the available evidence for guideline-recommended treatment options including medical therapy and revascularization, and propose a framework for synthesizing complex treatment decisions in older adults with stable angina. Due to evolving goals of care in older patients, it is paramount to readdress the patient's priorities and preferences when deciding on treatment. Ultimately, the management of stable angina in older adults will need to be informed by dedicated studies in representative populations emphasizing patient-centered end points and person-centered decision-making.

Coronary Revascularization in Patients With Diabetes: A Meta-Analysis of Randomized Controlled Trials and Propensity-Matched Studies

OBJECTIVE

Patients with diabetes have poorer outcomes with coronary artery disease (CAD) and pose a unique clinical population for revascularization. We performed a pairwise meta-analysis of randomized trials (RCTs) and propensity-matched observational studies (PMS) to compare the clinical outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with diabetes.

METHODS

A comprehensive literature search was performed to identify RCT and PMS studies comparing CABG with PCI in patients with diabetes with concurrent CAD. Studies were pooled using the random-effects model to perform a pairwise meta-analysis. Primary outcomes included long-term all-cause mortality, cardiac mortality, myocardial infarction (MI), major adverse cardiac and cerebrovascular events (MACCE), and repeat revascularization. Meta-regression was used to explore the effects of baseline risk factors on primary outcomes with moderate to high heterogeneity.

RESULTS

A total of 18 RCTs and 9 PMS with 28,846 patients were included. PCI was associated with increased long-term all-cause mortality (risk ratio [RR] = 1.34, P < 0.001), cardiac mortality (RR = 1.52, P < 0.001), MI (RR = 1.51, P = 0.009), MACCE (RR = 1.65, P < 0.001), and repeat revascularization (RR = 2.48, P < 0.001) compared with CABG. There was no difference in long-term stroke between the 2 groups (RR = 0.95, P = 0.82). At meta-regression, a greater proportion of female patients in studies was associated with a decreased protective benefit for CABG for long-term all-cause mortality but an increased protective benefit for long-term MI and repeat revascularization.

CONCLUSIONS

Revascularization of patients with diabetes using CABG is associated with significantly reduced long-term mortality, MI, MACCE, and repeat revascularizations. Future studies exploring the influence of gender on revascularization outcomes are necessary to elucidate the ideal treatment modality in patients with diabetes.

Comparative Effectiveness of Coronary Artery Bypass Graft Surgery and Percutaneous Coronary Intervention for Patients With Coronary Artery Disease: A Meta-Analysis of Randomized Clinical Trials

Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery are the options for revascularization in coronary artery disease (CAD). This meta-analysis aims to compare the efficacy of CABG and PCI for the management of patients with CAD. The meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane Library, and EMBASE were searched for relevant articles. The reference list of included articles was also searched manually for additional publications. Primary endpoints were cardiovascular mortality and all-cause mortality. Secondary endpoints included myocardial infarction, stroke, and revascularization. In total, 12 randomized control trials (RCTs) were included in this meta-analysis encompassing 9,941 patients (4,954 treated with CABG and 4,987 with PCI). The analysis showed that PCI was associated with a higher risk of all-cause mortality (risk ratio (RR) = 1.26, 95% confidence interval (CI) = 1.10-1.45) and revascularization (RR = 2.42, 95% CI = 1.82-3.21). However, no significant differences were reported between two arms regarding cardiovascular mortality (RR = 1.15, 95% CI = 0.96-1.39), myocardial infarction (RR = 1.17, 95% CI = 0.82-1.67), and stroke (RR = 0.64, 95% CI = 0.35-1.16). CABG was associated with a significant reduction in all-cause mortality and revascularization compared to PCI. However, no significant difference was reported in the risk of cardiovascular mortality, myocardial infarction, and stroke between the two groups.

Epidemiology of Coronary Artery Disease

Although the mortality of coronary artery disease (CAD) has declined over recent decades, CAD remains the leading cause of death in the United States (US) and presents a significant economic burden. Epidemiologic studies have identified numerous risk factors for CAD. Some risk factors-including smoking, hypertension, dyslipidemia, and physical inactivity-are decreasing within the US population while Others, including advanced age, diabetes, and obesity are increasing. The most significant historic advances in CAD therapy were the development of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and lipid-lowering medications. Contemporary management of CAD includes primary and secondary prevention via medical management and revascularization when appropriate based on best available evidence. Despite the increasing prevalence of CAD nationwide, there has been a steady decline in the number of CABGs and PCIs performed in the US for the past decade. Patients with CABG are becoming older and with more comorbid conditions, although mortality associated with CABG has remained steady.

Comparison of Coronary Artery Bypass Grafting and Drug-Eluting Stent Implantation in Patients With Chronic Kidney Disease: A Propensity Score Matching Study

Objectives

To compare the long-term outcomes of coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) for coronary artery disease (CAD) patients with chronic kidney disease (CKD).

Methods

Coronary artery disease patients with decreased kidney function (estimated glomerular filtration rate &lt;60 ml/min/1.73 m2) who underwent CABG (n = 533) or PCI with DES (n = 952) from 2013 to 2020 were enrolled at a single center. The baseline characteristics and clinical outcomes were compared between the CABG and PCI groups for each matched pair of patients with CKD. The primary endpoint was the occurrence of all-cause death. The secondary endpoints were major adverse cardiovascular events (MACCEs) such as death, myocardial infarction (MI), stroke, and repeat revascularization.

Results

A total of 1,485 patients underwent revascularization, such as 533 CABG and 952 patients with PCI. The median follow-up duration was 55.6 months (interquartile range 34.3–74.7 months). Multivariable Cox regression models were used for risk adjustment, and after propensity score matching (PSM), 399 patients were well matched in each group. The in-hospital mortality rate in the CABG group was higher than that in the PCI group, but the difference was not statistically significant (5.0 vs. 2.5%, p = 0.063). At the 1-year follow-up, CABG was associated with a lower survival rate than PCI (94.2 vs. 98.0%, hazard ratio [HR] of 3.72, 95% CI = 1.63–8.49, p &lt; 0.01). At the end of the 5-year follow-up, the freedom from MI and the freedom from repeated revascularization were both better in the CABG group compared to the PCI group (89.1 vs. 81.7%, HR of 0.59, 95% CI = 0.38–0.92, p = 0.019; 86.9 vs. 73.8%, HR of 0.54, 95% CI = 0.36–0.81, p = 0.003, respectively). Furthermore, the freedom from MACCEs was also better in the patients of CABG compared with the patients of PCI (58.5 vs. 51.3%, HR of 0.71, 95% CI = 0.55–0.91, p = 0.030). CABG had a higher cumulative survival rate (68.4 vs. 66.0%) but without a statistically significant difference (HR of 0.92, 95% CI = 0.67–1.27, p = 0.602) compared with that of PCI.

Conclusions

Compared to the use of PCI with a drug-eluting stent among patients with CKD, the use of CABG was associated with a lower MI rate, repeat revascularization rate, and lower number of MACCEs during the long-term follow-up. At a follow-up of 1 year, the number of MACCEs and other adverse events were comparable between the two cohorts, but CABG showed a lower survival rate than PCI.

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease: A One-Stage Meta-Analysis

Background and Aims

Data are emerging on 10-year mortality comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stenting for multivessel disease (MVD) without left main (LM) involvement. We conducted an updated two-stage meta-analysis using reconstructed individual patient data to compare long-term mortality between CABG and PCI for patients with MVD without significant LM coronary disease.

Methods

Medline and Embase databases were searched for articles comparing CABG with PCI for MVD. A two-stage meta-analysis was conducted using reconstructed patient level survival data for all-cause mortality with subgroups by SYNTAX score. The shared-frailty and stratified Cox models were fitted to compare survival endpoints.

Results

We screened 1,496 studies and included six randomized controlled trials with 7,181 patients. PCI was associated with greater 10-year all-cause mortality risk (HR: 1.282, CI: 1.118-1.469, p < 0.001) compared with CABG. In patients with low SYNTAX score, 10-year all-cause mortality after PCI was comparable to CABG (HR: 1.102, 0.822-1.479, p = 0.516). However, in patients with moderate to high SYNTAX score, 10-year all-cause mortality was significantly higher after PCI compared with CABG (HR: 1.444, 1.122-1.858, p < 0.001; HR: 1.856, 1.380-2.497, p < 0.001, respectively).

Conclusion

This updated reconstructed individual patient-data meta-analysis revealed a sustained lower cumulative all-cause mortality of CABG over PCI for multivessel disease without LM involvement.

Percutaneous Coronary Intervention with Stenting versus Coronary Artery Bypass Grafting in Stable Coronary Artery Disease

The debate over coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with stent placement for the treatment of stable multivessel coronary artery disease (CAD) continues in spite of numerous studies investigating the issue. This paper reviews the most recent randomized control trials (RCT) and meta-analyses of pooled RCT data to help address this issue. General trends demonstrated that CABG was superior in all-cause mortality and fulfilling the need for repeat revascularization. These advantages tended to be more pronounced in multivessel CAD and diabetes, and less so in left main CAD. PCI showed a consistently lower rate of cerebrovascular events. CABG continues to offer significant advantages over PCI, even as drug-eluting stent technology continues to evolve. The ideal endpoint for comparing PCI and CABG remains to be determined. Furthermore, additional research is required to further refine patient selection criteria for each intervention.

Real-world long-term outcomes based on three therapeutic strategies in very old patients with three-vessel disease

Background

There are relatively limited data regarding real-world outcomes in very old patients with three-vessel disease (3VD) receiving different therapeutic strategies. This study aimed to perform analysis of long-term clinical outcomes of medical therapy (MT), coronary artery bypass grafting (CABG), and percutaneous coronary intervention (PCI) in this population.

Methods

We included 711 patients aged ≥ 75 years from a prospective cohort of patients with 3VD. Consecutive enrollment of these patients began from April 2004 to February 2011 at Fu Wai Hospital. Patients were categorized into three groups (MT, n = 296; CABG, n = 129; PCI, n = 286) on the basis of different treatment strategies.

Results

During a median follow-up of 7.25 years, 262 deaths and 354 major adverse cardiac and cerebrovascular events (MACCE) occurred. Multivariate Cox analysis showed that the risk of cardiac death was significantly lower for CABG compared with PCI (adjusted hazard ratio [HR] = 0.475, 95% confidence interval [CI] 0.232–0.974, P = 0.042). Additionally, MACCE appeared to show a trend towards a better outcome for CABG (adjusted HR = 0.759, 95% CI 0.536–1.074, P = 0.119). Furthermore, CABG was significantly superior in terms of unplanned revascularization (adjusted HR = 0.279, 95% CI 0.079–0.982, P = 0.047) and myocardial infarction (adjusted HR = 0.196, 95% CI 0.043–0.892, P = 0.035). No significant difference in all-cause death between CABG and PCI was observed. MT had a higher risk of cardiac death than PCI (adjusted HR = 1.636, 95% CI 1.092–2.449, P = 0.017). Subgroup analysis showed that there was a significant interaction between treatment strategy (PCI vs. CABG) and sex for MACCE (P = 0.026), with a lower risk in men for CABG compared with that of PCI, but not in women.

Conclusions

CABG can be performed with reasonable results in very old patients with 3VD. Sex should be taken into consideration in therapeutic decision-making in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02067-6.

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with coronary heart disease and type 2 diabetes mellitus: Cumulative meta-analysis

Previous meta‐analyses showed that coronary artery bypass grafting (CABG) has lower all‐cause mortality than percutaneous coronary intervention (PCI) for the management of coronary heart disease (CHD), but the long‐term outcomes were not analyzed thoroughly in patients with type 2 diabetes mellitus (T2DM). To perform a meta‐analysis of randomized controlled trials (RCTs) to explore the long‐term effectiveness between CABG and PCI in patients with T2DM and study the temporal trends using a cumulative meta‐analysis. PubMed, Embase, Cochrane library, and Clinical Trials Registry for eligible RCTs published up to September 2020. The outcomes were all‐cause death, cardiac death, myocardial infarction, repeat revascularization, and stroke. Nine RCTs and 4566 patients were included. CABG resulted in better outcomes than PCI in terms of all‐cause death (RR = 1.41, 95%CI: 1.22–1.63, p < 0.001), cardiac death (RR = 1.56, 95%CI: 1.25–1.95, p < 0.001), and repeat revascularization (RR = 2.68, 95%CI: 1.86–3.85, p < 0.001), but with difference regarding the occurrence of myocardial infarction (RR = 1.20, 95%CI: 0.78–1.85, p = 0.414), while PCI was associated with better outcomes in terms of stroke occurrence (RR = 0.51, 95%CI: 0.34–0.77, p = 0.001). The cumulative meta‐analysis for all‐cause death showed that the differences between CABG and PCI started to be significant at 3 years of follow‐up, while the difference became significant at 5 years for cardiac death. In patients with CHD and T2DM, CABG results in better outcomes than PCI in terms of all‐cause death, cardiac mortality, and repeat revascularization, while PCI had better outcomes in terms of stroke. The differences are mainly observed over the long‐term follow‐up.

Empirical use of causal inference methods to evaluate survival differences in a real-world registry vs those found in randomized clinical trials

With heighted interest in causal inference based on real-world evidence, this empirical study sought to understand differences between the results of observational analyses and long-term randomized clinical trials. We hypothesized that patients deemed "eligible" for clinical trials would follow a different survival trajectory from those deemed "ineligible" and that this factor could partially explain results. In a large observational registry dataset, we estimated separate survival trajectories for hypothetically trial-eligible vs ineligible patients under both coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI). We also explored whether results would depend on the causal inference method (inverse probability of treatment weighting vs optimal full propensity matching) or the approach to combine propensity scores from multiple imputations (the "across" vs "within" approaches). We found that, in this registry population of PCI/CABG multivessel patients, 32.5% would have been eligible for contemporaneous RCTs, suggesting that RCTs enroll selected populations. Additionally, we found treatment selection bias with different distributions of propensity scores between PCI and CABG patients. The different methodological approaches did not result in different conclusions. Overall, trial-eligible patients appeared to demonstrate at least marginally better survival than ineligible patients. Treatment comparisons by eligibility depended on disease severity. Among trial-eligible three-vessel diseased and trial-ineligible two-vessel diseased patients, CABG appeared to have at least a slight advantage with no treatment difference otherwise. In conclusion, our analyses suggest that RCTs enroll highly selected populations, and our findings are generally consistent with RCTs but less pronounced than major registry findings.

Arrhythmias in Patients after Surgical Myocardial Revascularization

This work represents literature review data regarding the study of the effect of surgical myocardial revascularization on the processes of electrical myocardial instability underlying the onset of life-threatening ventricular arrhythmias, as well as the possibilities for its non-invasive assessment by studying the heart rhythm variability and turbulence. Analyzed data demonstrated that, relying only on the presence of a viable myocardium, it is often impossible to predict the positive effect of revascularization on the prognosis in patients, especially those with reduced myocardial contractility. Considering the well-studied relationship between myocardial remodeling and neurohormonal activation, such non-invasive methods for assessing vegetative regulation of cardiac activity, as heart rate variability and turbulence may provide additional diagnostic information. The literature data indicate that heart failure, ventricular arrhythmias and recurrences of angina and myocardial infarction are the main problems that determine an unfavorable outcome in the postoperative period. There is important evidence that violations of the vegetative regulation of the heart, the heterogeneity of repolarization processes in the myocardium are integral indicators of the morphofunctional changes occurring in the process of coronary heart disease (CHD) progression. The role of indicators of heart rate variability and turbulence as predictors of sudden cardiac death was proved, mainly due to fatal ventricular heart rhythm disorders and cardiovascular mortality. Along with this, changes in these indicators, and their prognostic role in patients with CHD in revascularization are the subject of discussion, which determines the relevance of further studies on the effect of various methods of revascularization on the electrical instability of the myocardium, as one of the most important factors in the development of life-threatening ventricular arrhythmias that are predictors of sudden cardiac death, especially in patients who previously had acute myocardial infarction. Besides it is important to study the effect of myocardial revascularization on the indicators of cardiac autonomic regulation and the possibility of their use as prognostic criteria before and after surgery.

Coronary artery bypass vs percutaneous coronary intervention in under 50s

BACKGROUND

Young patients with coronary artery disease are undergoing percutaneous coronary intervention (PCI) primarily, with a view to deferring coronary artery bypass grafting (CABG). We investigated the validity of this approach, by comparing outcomes in patients ≤50 years undergoing CABG or PCI.

METHODS

One hundred consecutive patients undergoing PCI and 100 undergoing CABG in 2004 were retrospectively studied to allow for 5 and 12 years follow-up. The two groups were compared for the primary endpoints of major adverse cardiac or cerebrovascular event (MACCE).

RESULTS

Diabetes, peripheral vascular disease, and left ventricular ejection fraction <50% were higher in the CABG group. At 5 years, rates of myocardial infarction (MI) (9% vs 1%, P = .02), repeat revascularization (31% vs 7%, P < .01), and MACCE (34 vs 12, P < .01) were greater in the PCI vs the CABG group. Similarly, at 12 years, rates of MI (27.4% vs 19.4%, P = .19), repeat revascularization (41.1% vs 20.4%, P < .01), and MACCE (51 vs 40, P = .07) were greater in the PCI group. There were no differences in major outcomes in patients with 1 or 2VD, at 5 or 12 years. Rates of MI, revascularization, and MACCE were higher in patients with 3VD undergoing PCI (n = 21; MI, 47.6%; revascularization, 66.7%; and MACCE, 19 events) vs CABG (n = 78; MI, 19.2%; revascularization, 20.5%; and MACCE, 31 events); P < .01, for all end points.

CONCLUSIONS

MACCE was lower in young patients undergoing CABG vs PCI at both 5 and 12 years follow-up, primarily as a consequence of patients with 3VD undergoing PCI having more MI and repeat revascularization. CABG should remain the preferred method of revascularization in young patients with 3VD.

Meta-Analysis Comparing the Risk of Myocardial Infarction Following Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients With Multivessel or Left Main Coronary Artery Disease

There is insufficient data regarding the comparative efficacy of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) regarding myocardial infarction (MI). Our systematic review included randomized controlled trials that compared CABG versus PCI with stents in patients with multivessel or left main coronary artery disease (CAD). Included trials should have had reported event number of MI and a clinical follow-up of one or more years. Data were pooled using a random-effects model. The primary end point was MI at the longest available follow-up in the intention-to-treat population. Fifteen trials with a total of 13,592 patients treated with either CABG (n = 6,596) or PCI (n = 6,996) were included. After a weighted follow-up of 4.5 years, patients treated with CABG had a significantly lower risk of MI than those treated with PCI (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.58 to 0.96, p = 0.024). The lower risk of MI with CABG as compared with PCI was more evident during a longer duration of follow-up (≥3 years, RR 0.69, 95% CI 0.52 to 0.91, p = 0.008; ≥5 years, RR 0.64, 95% CI 0.48 to 0.86, p = 0.003) and in the diabetic population (RR 0.55, 95% CI 0.44 to 0.70, p <0.001). The magnitude of risk reduction was similar across patients with multivessel (RR 0.72, 95% CI 0.53 to 0.99) and left main CAD (RR 0.74, 95% CI 0.47 to 1.15). In conclusion, the present meta-analysis of studies involving patients with multivessel or left main CAD suggests a significant benefit of CABG over PCI concerning the risk of future MI.

Compliance With Guideline-Directed Medical Therapy in Contemporary Coronary Revascularization Trials

BACKGROUND

Despite the well-established benefits of secondary cardiovascular prevention, the importance of concurrent medical therapy in clinical trials of coronary revascularization is often overlooked.

OBJECTIVES

The goal of this study was to assess compliance with guideline-directed medical therapy (GDMT) in clinical trials and its potential impact on the comparison between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG).

METHODS

The Cochrane Central Register of Controlled Trials and MEDLINE were searched from 2005 to August 2017. Clinical trial registries and reference lists of relevant studies were also searched. Randomized controlled trials comparing PCI with drug-eluting stents versus CABG and reporting medical therapy after revascularization were included. The study outcome was compliance with GDMT, defined as the following: 1) any antiplatelet agent plus beta-blocker plus statin (GDMT1); and 2) any antiplatelet agent plus beta-blocker plus statin plus angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (GDMT2). Data collection and analysis were performed according to the methodological recommendations of The Cochrane Collaboration.

RESULTS

From a total of 439 references, 5 trials were included based on our inclusion and exclusion criteria. Overall, compliance with GDMT1 was low and decreased over time from 67% at 1 year to 53% at 5 years. Compliance with GDMT2 was even lower and decreased from 40% at 1 year to 38% at 5 years. Compliance with both GDMT1 and GDMT2 was higher in PCI than in CABG at all time points. Meta-regression suggested an association between lower use of GDMT1 and adverse clinical outcomes in PCI versus CABG at 5 years.

CONCLUSIONS

Compliance with GDMT in contemporary clinical trials remains suboptimal and is significantly lower after CABG than after PCI, which may influence the comparison of clinical trial endpoints between those study groups.

Type 1 diabetes mellitus and coronary revascularization

Over the last three decades, trials of coronary revascularization have taken into account whether populations did or did not have diabetes. What has not been considered is whether or not patients with diabetes in these studies have type 1 or type 2 diabetes. 'Diabetes' appears to be largely used as a synonym for type 2 diabetes. The number of patients with type 1 diabetes has not been reported in most trials. Many questions remain unanswered. Do patients with type 1 diabetes have the same response to various modes of revascularization as those with type 2 diabetes? We know type 2 diabetes affects coronary endothelial function and the coronary artery wall but to what extent does type 1 diabetes affect these? Any response to revascularization does not just depend on the coronary artery but also on the myocardium. How does type 1 diabetes affect the myocardium? To what extent do patients with type 1 diabetes have viable or ischaemic myocardium or scar? What does 'diabetic cardiomyopathy' refer to in the context of type 1 diabetes? This manuscript reviews the evidence for revascularization in type 1 diabetes. We conclude that there has been a near absence of investigation of the pros and cons of revascularization in this population. Investigations to establish both the nature and extent of coronary and myocardial disease in these populations are necessary. Clinical trials of the pros and cons of revascularization in type 1 diabetes are necessary; many will declare that these will be too challenging to perform.

Stent versus Coronary Artery Bypass Surgery in Multi-Vessel and Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Trials with Subgroups Evaluation

Background

Comparison between percutaneous coronary intervention (PCI) using stents and Coronary Artery Bypass Grafting (CABG) remains controversial.

Objective

To conduct a systematic review with meta-analysis of PCI using Stents versus CABG in randomized controlled trials.

Methods

Electronic databases were searched to identify randomized trials comparing PCI using Stents versus CABG for multi-vessel and unprotected left main coronary artery disease (LMCAD). 15 trials were found and their results were pooled. Differences between trials were considered significant if p < 0.05.

Results

In the pooled data (n = 12,781), 30 days mortality and stroke were lower with PCI (1% versus 1.7%, p = 0.01 and 0.6% versus 1.7% p < 0.0001); There was no difference in one and two year mortality (3.3% versus 3.7%, p = 0.25; 6.3% versus 6.0%, p = 0.5). Long term mortality favored CABG (10.6% versus 9.4%, p = 0.04), particularly in trials of DES era (10.1% versus 8.5%, p = 0.01). In diabetics (n = 3,274) long term mortality favored CABG (13.7% versus 10.3%; p < 0.0001). In six trials of LMCAD (n = 4,700) there was no difference in 30 day mortality (0.6%versus 1.1%, p = 0.15), one year mortality (3% versus 3.7%, p = 0.18), and long term mortality (8.1% versus 8.1%) between PCI and CABG; the incidence of stroke was lower with PCI (0.3% versus 1.5%; p < 0.001). Diabetes and a high SYNTAX score were the subgroups that influenced more adversely the results of PCI.

Conclusion

Compared with CABG, PCI using Stents showed lower 30 days mortality, higher late mortality and lower incidence of stroke. Diabetes and a high SYNTAX were the subgroups that influenced more adversely the results of PCI.

Second-generation drug-eluting stenting versus coronary artery bypass grafting for treatment of coronary chronic total occlusion

BACKGROUND

Limited data are available regarding the long-term clinical outcomes of percutaneous coronary intervention (PCI) using second-generation drug-eluting stents (DESs) versus coronary artery bypass grafting (CABG) for the treatment of coronary artery disease (CAD) with chronic total occlusion (CTO). We compared the clinical outcomes of patients with multivessel CAD including CTO lesions treated with PCI using DESs versus CABG.

METHODS

We analyzed data from 423 consecutive patients who underwent successful revascularization for CTO between March 2008 and February 2012. Death or myocardial infarction (MI) and major adverse cardiac and cerebrovascular events (MACCE) were compared between patients treated with PCI using second-generation DESs (n=232, 2nd DES group) versus those treated with CABG (n=191, CABG group). To reduce selection bias according to treatment strategy and other potential confounding factors, inverse probability of treatment weighting (IPTW) was also performed.

RESULTS

During a median follow-up duration of 32 months, there was no significant difference in death or MI [hazard ratio (HR): 0.69; 95% confidence interval (CI): 0.29-1.63; p=0.399] or MACCE (HR: 1.32; 95% CI: 0.74-2.35; p=0.341) between the 2nd DES group and the CABG group based on multivariable analysis. After IPTW adjustment, the incidences of death or MI (HR: 0.72; 95% CI: 0.26-1.95; p=0.518) and MACCE (HR: 1.49; 95% CI: 0.76-2.91; p=0.244) remained similar in the two groups. In subgroup analysis, the effect of second-generation drug-eluting stenting was comparable to that of CABG across various subgroups without a significant p-value for the interaction.

CONCLUSIONS

The efficacy of PCI using second-generation DES was comparable to that of CABG in CTO patients with multivessel CAD.

Pivotal contemporary trials of percutaneous coronary intervention vs. coronary artery bypass grafting: a surgical perspective

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are the two revascularization strategies for patients with coronary artery disease (CAD). While CABG continues to be the gold standard for revascularization, advancements in PCI technology have triggered numerous, often industry-funded investigations to challenge this role. This perspective will provide a summary of previous RCTs comparing CABG vs. PCI. The recently published NOBLE and EXCEL trials will be discussed in depth. Future directions of research pertaining to CABG vs. PCI will be briefly discussed in this document.

Quality of life after coronary artery bypass graft surgery versus percutaneous coronary intervention: what do the trials tell us?

PURPOSE OF REVIEW

With an ever-aging population, the treatment of multi-vessel coronary artery disease (CAD) has increasingly become focused not only on mortality, but on symptom relief and improving quality of life (QOL). The purpose of this review is to present a summary on the subject of QOL after percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG), highlighting the latest comparative trials in the field.

RECENT FINDINGS

About 1 month after revascularization, patients recovering from either PCI or CABG report improvements in angina frequency. However, at 6 months and in the years that follow, angina relief is significantly better after CABG compared with PCI. Correspondingly, the use of antiangina medication is significantly higher following PCI, even in recent years with the use of drug-eluting stents. Regarding general health status, at the 1-month time point, PCI patients have recovered faster than those who have had surgery, reporting fewer physical limitations, less bodily pain, and greater QOL and treatment satisfaction. Nevertheless, these differences disappear by 6 months, and in the years thereafter, CABG patients report fewer physical limitations compared with those who have undergone PCI. About 5 years after revascularization, significant benefits remain favoring CABG in term of physical, emotional, and mental health.

SUMMARY

Patients with multivessel coronary artery disease attain important QOL benefits following revascularization with either PCI or CABG. Percutaneous treatments lead to a more rapid recovery and improved short-term health status compared with CABG at 1 month. However, surgery results in greater angina relief and improved QOL compared with PCI 6 months after revascularization and beyond.

The Potential Effects of New Stent Platforms for Coronary Revascularization in Patients With Diabetes

Coronary artery disease in patients with diabetes mellitus (DM) is characterized by extensive atherosclerosis, longer lesions, and diffuse distal disease. Consequently, these patients have worse outcomes after coronary revascularization, regardless of the modality used. Traditionally, coronary artery bypass grafting (CABG) has been regarded as more effective than percutaneous coronary intervention (PCI) in patients with DM, likely because of more complete revascularization and protection against disease progression in the bypass segment. Revascularization with balloon angioplasty, bare-metal stents, and first-generation drug-eluting stents have all been shown to be inferior to CABG in patients with DM. Current professional society guidelines reflect these findings, strongly recommending CABG over PCI in this setting. Newer stent platforms, however, have challenged this notion. The use of thinner struts, biocompatible polymer coating, and newer antiproliferative agents have improved the rates of cardiovascular events in patients with DM revascularized percutaneously. Since the publication of current guidelines, new studies suggested acceptable outcomes in patients with DM revascularized with second-generation drug-eluting stents, even though these conclusions are drawn from small subgroup analyses or nonrandomized studies. Robust registry data suggest similar mortality with lower rates of stroke after PCI compared with surgery, at the expense of increased rates of repeat revascularization. If complete revascularization can be achieved, similar rates of myocardial infarction are also observed. Therefore, contemporary revascularization in patients with DM with multivessel coronary artery disease should involve a multidisciplinary approach, in which interventional cardiologists and cardiac surgeons involve their patients to individualize treatment choices, and balance the risks and effectiveness of each modality.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Graft in Acute Coronary Syndrome patients with Renal Dysfunction

ACS patients with renal dysfunction tend to have a poorer prognosis than those with normal renal function. This retrospective cohort study was performed using The Second Drug-Eluting Stent Impact on Revascularization Registry, a retrospective registry, to evaluate the time-dependent relative risk of revascularization strategies in ACS patients with renal dysfunction. The study demonstrated that the short-term MACCE rate was lower after PCI than CABG. However, there was no significant difference in long-term MACCE rate. Subgroup analyses based on the degree of renal dysfunction resulted in similar findings. The revascularization strategy was identified as a time-dependent covariate by the time-dependent Cox model, and the regression coefficient was ‘−1.124 + 0.344 × ln (time + 1)’. For the entire object group and the separate subgroups, PCI was initially associated with a lower hazard for MACCE than CABG after revascularization, then the hazard ratio increases with time. In conclusion, the hazard ratio for MACCE in PCI relative to CABG is time-dependent. PCI tends to have a lower risk for MACCE than CABG in the short-term, then the hazard ratio increases with time.

Revascularization for Left Main and Multivessel Coronary Artery Disease: Current Status and Future Prospects after the EXCEL and NOBLE Trials

Revascularization of severe left main and multivessel coronary artery disease has been shown to improve survival in both stable ischemic heart disease and acute coronary syndrome. While revascularization with coronary artery bypass surgery for these disease entities carries class I recommendation in most current guidelines, recent trials has shown potential comparable survival and cardiovascular outcomes between percutaneous and surgical interventions in patients with less complex coronary anatomy. Despite the conflicting results observed in the most recent left main revascularization trials, Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease (EXCEL) and Nordic-Baltic-British left main revascularization (NOBLE), both treatment strategies remain important for the management of left main disease (LMD) and multivessel disease (MVD) reflecting on the importance of heart team discussion. This review is focused on revascularization of LMD and MVD in patients who are not presenting with ST-segment elevation myocardial infarction, encompassing the evidence from historic and contemporary trials which shaped up current practices. This review discusses the heart team approach to guide decision making, including special populations that are not represented in clinical trials.

Comparative Efficacy of Coronary Revascularization Procedures for Multivessel Coronary Artery Disease in Patients With Chronic Kidney Disease

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular disease and death, yet little data exist regarding the comparative efficacy of coronary revascularization procedures in CKD patients with multivessel disease. We created a cohort of 4,687 adults who underwent cardiac catheterization, had a serum creatinine value measured within 30 days, and had more than one vessel with ≥50% stenosis. We used Cox proportional hazard regression modeling weighted by the inverse probability of treatment to examine the association between 4 treatment strategies (medical management, percutaneous coronary intervention [PCI] with bare metal stent, PCI with drug-eluting stent, and coronary artery bypass grafting [CABG]) and mortality among patients across categories of estimated glomerular filtration rate; secondary outcome was a composite of mortality, myocardial infarction, or revascularization. Compared with medical management, CABG was associated with a reduced risk of death for patients of any nondialysis CKD severity (hazard ratio [HR] range 0.43 to 0.59). There were no significant mortality differences between CABG and PCI, except a decreased death risk in CABG-treated CKD patients (HR range 0.54 to 0.55). Compared with medical management and PCI, CABG was associated with a lower risk of death, myocardial infarction, or revascularization in nondialysis CKD patients (HR range 0.41 to 0.64). There were similar associations between decreased estimated glomerular filtration rate and increased mortality across all multivessel coronary artery disease patient treatment groups. When accounting for treatment propensity, surgical revascularization was associated with improved outcomes in patients of all CKD severities. A prospective randomized trial in CKD patients is required to confirm our findings.

Mortality in isolated coronary artery bypass surgery in elderly patients. A retrospective analysis over 14 years

INTRODUCTION

We aim to describe our experience in coronary artery bypass graft in elderly patients older than 80 years and assess the associated risk and predictors of mortality in this subgroup.

MATERIAL AND METHOD

From January 1999 to June 2013, 3097 patients underwent consecutive coronary artery bypass graft surgery. Patients aged over 80 years were identified. Multivariate survival analysis using Cox's regression model was performed.

RESULTS

We identified 99 patients older than 80 years (80-group; mean age 82±3.5 years) and 2957 younger than 80 years (control group) (mean age 64.2±9.7 years). Additive EuroSCORE was 8.4±4.8 and 4.6±4.6 (P<.001) in the 80-group vs. control group, respectively. Off-pump coronary artery bypass graft was performed in 79.6 vs. 41.6% (P<.001) in the 80-group vs. the control group. respectively. There was significantly higher 30 day-mortality in the 80-group, 11.2 vs. 3.3%, respectively (P<.001). Patients in the 80-group underwent reintervention for bleeding more frequently (9.2 vs. 2.9%; P=.001) and had a higher incidence of major cardiovascular complications than the control group (6.1 vs. 2.1%; P=.001). Independent predictors of mortality for the 80-group were: reoperation for bleeding (HR 5.7; 95% CI 1.6-19.5) and cardiovascular complications (HR 3.7; 95% CI 1.1-12.2). The mean follow-up was 6.3±4.2 years for the octogenarian group. The cumulative survival of these patients was 65.7% during the study period.

CONCLUSION

Coronary artery bypass graft is performed preferably in patients over 80 years old under the off-pump procedure. Mortality is higher in this group of patients probably related to a higher incidence of cardiovascular complications and reintervention for bleeding in the immediate postoperative period.

Very Long-Term (10 to 14 Year) Outcomes After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease in the Bare-Metal Stent Era

BACKGROUND

Many of the previous randomized trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease reported equivalent or better survival with CABG as compared with PCI at 5-year follow-up. However, 5-year follow-up might be too short to evaluate the true differences in long-term clinical outcomes between PCI and CABG.

METHODS AND RESULTS

Among 8934 patients enrolled in the extended 10- to 14-year follow-up study of the CREDO-Kyoto registry cohort-1 (Coronary Revascularization Demonstrating Outcome study in Kyoto) conducted in the bare-metal stent era, 5152 (PCI: n=3490 and CABG: n=1662) patients had multivessel coronary artery disease without left main disease. Median follow-up duration was 11.2 (interquartile range: 10.2-12.2) years. The cumulative 10-year incidence of all-cause death was not significantly different between PCI and CABG (32.2% versus 31.7%; log-rank P=0.93). After adjusting for confounders, however, the mortality risk of PCI was significantly higher than that of CABG (hazard ratio, 1.19 [95% confidence interval, 1.02-1.39]; P=0.03). Within 5 years after the index procedure, the risk for all-cause death was significantly higher after PCI than after CABG (hazard ratio, 1.41; 95% CI, 1.12-1.79; P=0.004). By a landmark analysis at 5 years, however, the cumulative 10-year incidence of and adjusted risk for all-cause death beyond 5 years were not significantly different between PCI and CABG (19.3% versus 20.0%; log-rank P=0.22 and hazard ratio, 1.02, 95% confidence interval, 0.83-1.26; P=0.82).

CONCLUSIONS

CABG as compared with PCI was associated with better 10-year survival in patients with multivessel coronary artery disease. However, the benefit of CABG compared with PCI on late mortality beyond 5 years was not observed in this study.

Myocardial Revascularization for Patients With Diabetes: Coronary Artery Bypass Grafting or Percutaneous Coronary Intervention?

Patients affected by diabetes usually have extensive coronary artery disease. Coronary revascularization has a prominent role in the treatment of coronary artery disease in the expanding diabetic population. However, diabetic patients undergoing coronary artery bypass grafting or percutaneous coronary intervention experience worse outcomes than nondiabetic patients. Several studies comparing coronary artery bypass grafting vs percutaneous coronary intervention in subgroups of diabetic patients demonstrated a survival advantage and fewer repeat revascularization procedures with an initial surgical strategy. This review summarizes the current state of evidence comparing the effectiveness and safety of coronary artery bypass grafting and percutaneous coronary intervention in diabetic patients.

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

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 Outcome Study 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.

Adverse events following percutaneous and surgical coronary revascularisation: Analysis of non-MACE outcomes in the Stent or Surgery (SoS) Trial

OBJECTIVES

To analyse adverse events requiring or prolonging hospitalisation in the Stent or Surgery (SoS) trial.

BACKGROUND

Many adverse events following coronary revascularisation are non-major adverse cardiovascular events (non-MACE). Trials comparing percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) have reported rates of mortality and MACE only.

MATERIAL AND METHODS

Comparisons between PCI and CABG groups in the SOS trial were by intention to treat. For patients with non-fatal/non-MACE, number of events per 100 patient years follow-up and duration of hospital stay were assessed. Competing risk analysis was used to illustrate temporal pattern of adverse outcomes.

RESULTS

During 2 y median follow up, 1 one or more adverse event occurred in 47.3% (231) of the PCI group and 53% (265) of the CABG group (p=0.086). Non-fatal/non-MACE occurred in 11.9% of the PCI group and 38.6% of the CABG group (p<0.001). Non-fatal/non-MACE per 100 patient years follow-up was 17.49 (PCI) and 35.04 (CABG), rate ratio 2.0, 95% CI 1.7 to 2.4, p<0.001. Cumulative non-fatal/non-MACE associated hospital stays were 1387 and 3287 days in PCI and CABG groups respectively. Median duration of hospitalisation per non-fatal/non-MACE was 5 days (interquartile range 2 to 11.75 days) in the PCI group and 6 days (interquartile range 2 to 12 days) in the CABG group, p=0.245.

CONCLUSIONS

CABG had lower cumulative incidence of fatal or MACE outcomes, higher cumulative incidence of non-fatal/non-MACE outcomes, and longer cumulative hospitalisation periods compared to the PCI group.

CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting

BACKGROUND

Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES).

OBJECTIVES

This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG).

METHODS

We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts.

RESULTS

BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001).

CONCLUSIONS

Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.

Has the difference in mortality between percutaneous coronary intervention and coronary artery bypass grafting in people with heart disease and diabetes changed over the years? A systematic review and meta-regression

OBJECTIVES

To examine the difference in outcome between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), to see if it has changed over the years in diabetics deemed eligible for both treatments; and to contrast the long-term mortality findings with those in non-diabetics.

DESIGN

Meta-analyses using data from randomised controlled trials found by searches on MEDLINE, EMBASE and the Cochrane Controlled Trials Register, from their inception until March 2015.

SETTING

Studies had to be randomised controlled trials comparing PCI with CABG.

PARTICIPANTS

Those taking part in the studies had to have multivessel cardiac or left main artery cardiac disease and be deemed eligible for both treatments.

INTERVENTIONS

PCI or CABG.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was all cause mortality. Secondary outcomes were a composite of mortality, stroke and myocardial infarction; cardiovascular death; and MACCE (Major Adverse Cardiac or Cerebrovascular Event). The longest follow-up was used in the analysis.

RESULTS

Among 14 studies (4868 diabetics) reported over three decades, meta-regression shows no relationship between the year of publication and the difference in long term all cause mortality between PCI and CABG. CABG has maintained an approximately 30% mortality advantage compared to PCI. The other outcomes used showed the same lack of change over the years. These findings held true among insulin-requiring and non-insulin-requiring diabetics. However, among non-diabetics included in the 14 studies, there was no difference in mortality outcome between PCI and CABG.

CONCLUSIONS

The difference in outcome between PCI and CABG in diabetics has not narrowed from the beginning-with balloon angioplasty to current PCI-with the second generation of drug eluting stents. In contrast to the non-diabetics, there is a persistent 30% benefit in all cause mortality favouring CABG in diabetics, and this should be a major factor in treatment recommendation.

Coronary revascularization in the elderly with stable angina

A proportion of elderly with coronary artery disease is rapidly growing. They have more severe coronary artery disease, therefore, derive more benefit from revascularization and have a greater need for it. The elderly is a heterogeneous group, but compared to the younger cohort, the choice of the optimal revascularization method is much more complicated among them. In recent decades, results has improved dramatically both in surgery and percutaneous coronary intervention (PCI), even in very old persons. Despite the lack of evidence in elderly, it is obvious, that coronary artery bypass surgery (CABG) has a more pronounced effect on long-term survival in price of more strokes, while PCI is certainly less invasive. Age itself is not a criterion for the selection of treatment strategy, but the elderly are often more interested in quality of life and personal independence instead of longevity. This article discusses the factors that influence the choice of the revascularization method in the elderly with stable angina and presents a complex algorithm for making an individual risk-benefit profile. As a consequence the features of CABG and PCI in elderly patients are exposed. Emphasis is centered on the frailty and non-medical factors, including psychosocial, as essential components in making the decision of what strategy to choose. Good communication with the patients and giving them unbiased information is encouraged.

Description of a Heart Team approach to coronary revascularization and its beneficial long-term effect on clinical events after PCI

OBJECTIVE AND BACKGROUND

We present a first description of a Heart Team (HT)-guided approach to coronary revascularization and its long-term effect on clinical events after percutaneous coronary intervention (PCI). The HT approach is a structured process to decide for coronary bypass grafting (CABG), PCI or conservative therapy in ad hoc situations as well as in HT conferences. As a hypothesis, during the long-term course after a PCI performed according to HT rules, a low number of late revascularizations, especially CABGs, are expected (F-PCI study).

METHODS

In this monocentric study, the HT approach to an all-comer population was first analyzed and described in general with the help of a database. Next the use of a HT approach was described for a more homogeneous subgroup with newly detected CAD (1.CAD). Those patients in whom the HT decision was PCI (which was a 1.PCI) were then studied with the help of questionnaires for clinical events during a very long-term follow-up. Events were CABG, PCI, diagnostic catheterization (DCath) and death.

RESULTS

A significant number of patients were presented to HT conferences: 22 % out of all 11,174 catheterizations, 24 % out of all 7867 CAD cases and 35 % out of 3408 1.CAD cases. Most of these patients had multi-vessel disease (MVD). Conference decisions were isolated CABG in 46-66 %, PCI in 10-14 %, valvular surgery in 9-16 %, HTx in 10-21 % (Endstage heart failure candidates for surgery) and conservative therapy (Medical or no therapy, additional diagnostic procedures or no adherence to recommended therapy) in 2-3 %. However, most PCIs, ad hoc and elective, were performed under Heart Team rules, but without conference. During follow-up of 1.PCI patients (Kaplan-Meier analysis), CABG occurred in only 15 % of patients, PCI in 37 % and DCath in 65 %; mortality of any course was 51 %. Mortalities were similar in one-vessel disease and in a population of the same year, matched for age and sex (p < 0.057), but mortality was higher in 1.PCI patients with MVD (p < 0.001). Beyond 2 years, Kaplan-Meier curves were linear.

CONCLUSION

The structured Heart Team approach is an effective tool for ad hoc and conference-based clinical decision-making with a sustained clinical benefit. This is demonstrated in low late CABG (and PCI) rates after a 1.PCI, without elevated mortality. The all-comer population supports the universal value of these data. Stable annual event rates late after PCI suggest a conversion to stable CAD. Heart Team conferences are also important tools in cases of valvular and end-stage heart disease.

Optimal approaches to diabetic patients with multivessel disease

The pathophysiology of diabetes and systemic insulin resistance contributes to the nature of diffuse atherosclerosis and a high prevalence of multivessel coronary artery disease (CAD) in diabetic patients. The optimal approach to this patient population remains a subject of an ongoing discussion. In this review, we give an overview of the unique pathophysiology of CAD in patients with diabetes, summarize the current state of therapies available, and compare modalities of revascularization that have been investigated in recent clinical trials. We conclude by highlighting the importance of a comprehensive heart team approach to every patient while accommodating both patient preference and quality-of-life decisions.