High-risk Patients With Coronary Artery Disease May do Better With CABG Than PCI
Coronary artery bypass grafting (CABG) is associated with better survival than percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD) and multiple risk factors, according to a study at the Cleveland Clinic Foundation. The authors note that, in contrast, most randomized trials comparing the two approaches have shown that they “are equivalent” in terms of long-term survival.
Dr. Sorin J. Brener and associates write in the rapid access issue of Circulation, published online April 27, that high risk patients are “consistently excluded” from comparative trials. They found that real-world patients fared better with CABG, even when PCI frequently involved the use of stents and glycoprotein IIb/IIIa inhibitors.
The Ohio-based investigators studied over 6000 consecutive patients treated between 1995 and 1999, of whom 872 were treated with PCI and 5161 with CABG. Many risk factors, such as diabetes, hypertension, kidney and lung disease, and decreased left ventricular ejection fraction, were significantly more prevalent in the CABG group.
During median follow-up of 5.2 years, the unadjusted hazard ratio for death was 1.13 for PCI versus CABG (p = 0.07). After adjustment for risk factors, PCI was associated with a hazard ratio of 2.1 (p < 0.0001). CABG was associated with significantly better outcomes in patients with diabetes, and a trend toward better outcomes in those with ejection fraction of 30% or less. Drug-coated stents and routine use of more potent antiplatelet therapy are PCI modifications introduced since their cohort was treated, Dr. Brener’s group points out. And the low perioperative mortality rate at the Cleveland Clinic compared with other institutions may limit the generalizability of their findings. “Further research is needed to determine whether drug-eluting stents and improved medical management will close the mortality gap” in patients with multivessel CAD and many high-risk features, they conclude. Circulation 2004;109.
