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CABG confers improved outcomes in non-STEMI compared with PCI, medical therapy
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Patients with non-STEMI and either left main or multivessel coronary disease who underwent optimized medical therapy had worse outcomes compared with those who underwent CABG or PCI, according to a study published in The American Journal of Cardiology.
In addition, when the researchers performed a propensity-matched analysis of CABG vs. PCI in this population, they found a trend toward higher 5-year mortality in the PCI group.
Pedro Freitas, MD, of the department of cardiology at Hospital de Santa Cruz in Carnaxide, Portugal, and colleagues analyzed data from 1,104 patients with non-STEMI and left main or multivessel coronary disease who underwent CABG (n = 289; mean age, 69 years; 77% men), PCI (n = 399; mean age, 69 years; 71% men) or optimized medical therapy (n = 416; mean age, 74 years; 67% men) between 2009 and 2014. A cath lab-based electronic database was used to collect information on clinical and anatomical variables such as pulmonary disease status, ischemic risk and left ventricular ejection fraction.
Researchers also propensity-score matched 159 patients who underwent PCI with 159 patients who underwent CABG.
The primary endpoint was all-cause mortality at 5 years.
All-cause mortality occurred in more patients treated with optimized medical therapy (48.3%) compared with those treated with PCI (29.6%) and CABG (25.3%).
The difference in long-term all-cause mortality in the PCI and CABG groups was not statistically significant (unadjusted HR = 1.2; 95% CI, 0.9-1.6). Patients treated with optimized medical therapy had a twofold increase in risk for 5-year all-cause mortality compared with those treated with PCI or CABG (unadjusted HR = 2; 95% CI, 1.7-2.5).
In the patients who were propensity-score matched, all-cause mortality occurred in 31% of patients who underwent PCI vs. 21% who underwent CABG (unadjusted HR = 1.59; 95% CI, 1.02-2.48), which was not statistically significant after adjustment (adjusted HR = 1.52; 95% CI, 0.93-2.5).
Long-term outcomes favored CABG in patients who had had left main disease, proximal left anterior descending disease, a LVEF less than 40% or a SYNTAX score greater than 23.
“Due to its retrospective nature, potential confounding might persist even after adequate [propensity score]-matching and multivariate analysis, although standardized differences were 10% for all the variables in the model,” Freitas and colleagues wrote. “As such, our results should be regarded as hypothesis-generating, especially the subgroup analysis where study underpower is almost a certainty. Even so, they are strongly supported by similar findings reported in the literature from ... randomized clinical trials and from a recent individual patient-data pooled analysis performed in a broader patient population.” – by Darlene Dobkowski
Disclosures: The authors report no relevant financial disclosures.
Perspective
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David P. Faxon, MD
This single-center observational registry showed that 5-year all-cause mortality was not different between PCI and CABG in patients with non-STEMI ACS; however, medical therapy had a twofold increased mortality. After propensity matching, CABG was numerically better than PCI, but given the smaller number of patients and events in this subgroup, it was not significant.
The study also showed that the subgroups of patients with high SYNTAX score, left main disease, proximal left anterior descending artery disease and low ejection fraction did better with CABG.
The strength of the paper is the long-term follow up of a contemporary registry, but as mentioned by the authors, selection bias is a significant issue that cannot be adequately adjusted for by the propensity analysis. The study is, however, consistent with other studies such as the SYNTAX and SYNTAX-2 study that showed equivalent outcome between PCI and CABG patients in selected subgroups of patients with multivessel disease.
The implications for practice are that in the “right” patient, PCI has a similar long-term mortality rate to CABG.
There are many factors that are not evaluated in this study such as lesion complexity and functional significance, as measured by fractional flow reserve that have an impact on outcomes. Future studies need to include these factors, and only a randomized trial can adequately evaluate the optimal revascularization strategy.
The lack of other endpoints such as MI and repeat revascularization is a limitation of this study and are also important in deciding the best revascularization strategy.
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