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CABG may improve long-term outcomes vs. PCI in patients with left main disease, high SYNTAX score
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PCI appears to be a feasible alternative to CABG in patients with unprotected left main disease with low or intermediate SYNTAX scores, but CABG confers greater survival benefit vs. PCI in patients with more complex disease, according to recent findings.
In the prospective study, researchers reviewed a revascularization registry database of Fuwai Hospital, Beijing, to identify 4,046 consecutive patients with unprotected left main disease who underwent CABG (n = 2,604) or PCI with drug-eluting stents (n = 1,442) at the hospital between 2004 and 2010.
According to the study background, cardiologists and surgeons made the decision to perform CABG of PCI on these patients based on the risk associated with each revascularization option or the patient’s preference. Patients who underwent PCI had a younger mean age (60 years) vs. those in the CABG cohort (62 years; P < .001) and had fewer comorbidities. Patients in the PCI group also were more likely to have two-vessel disease (n = 535; 37.1%), whereas those in the CABG group more commonly had three-vessel disease (n = 2,051; 78.8%).
All patients returned for a routine follow-up at 1 month, 6 months, and then annually after discharge. The study’s primary outcome measure was 3-year all-cause mortality.
The researchers defined the secondary outcome as a composite of death, nonfatal MI or nonfatal stroke.
In patients for whom complete SYNTAX score data were available, the researchers performed a subgroup analysis by low- or intermediate-risk (≤ 32) and high-risk (> 32) groups. Other subgroup analyses assessed the following: age, sex, diabetes, left ventricular ejection fraction, number of diseased vessels, unprotected left main bifurcation and EuroSCORE.
The researchers found that, at 30 days, the PCI group had a higher unadjusted mortality rate vs. the CABG group (0.8% vs. 0.3%; P = .03). In an analysis adjusting for an inverse probability-weighted approach, PCI was linked to an increased risk for 30-day mortality (adjusted OR = 5.3; 95% CI, 2.83-9.94) and composite outcome of death, nonfatal MI or nonfatal stroke (OR = 2.14; 95% CI, 1.7-2.7).
At 3-year follow-up, the researchers estimated all-cause mortality at 3.8% in the PCI group vs. 2.5% in the CABG group (log-rank P = .03). An analysis adjusted for differences in baseline risk factors revealed higher risks among PCI-treated patients for all-cause mortality (HR = 1.71; 95% CI, 1.32-2.21), as well as repeat revascularization (HR = 4.91; 95% CI, 3.91-6.16). No significant difference was seen, however, in the composite of death, MI or stroke between the two groups. The PCI group had a consistently lower adjusted risk for stroke vs. the CABG group (HR = 0.18; 95% CI, 0.13-0.26).
In the subgroup analysis by SYNTAX scores, the researchers found no significant difference in all-cause mortality between the two treatments in patients with SYNTAX scores up to 32. However, patients who underwent PCI with SYNTAX scores greater than 32 (comprising 31.2% of the whole cohort) had significantly higher adjusted risks for all-cause death (HR = 3.1; 95% CI, 1.84-5.22) and composite outcome (HR = 1.82; 95% CI, 1.36-2.45) vs. CABG patients at high risk.
According to the researchers, these findings suggest that CABG should be considered in patients with high SYNTAX scores.
“The optimum revascularization strategy for an individual patient should balance the risks and benefits associated with each procedure in conjunction with the baseline risk profile and patient preferences,” the researchers wrote. “Adequately powered randomized trials are needed to confirm the safety and efficacy of CABG and PCI with later-generation [DES] in patients with [unprotected left main disease].” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures.
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