In very low LVEF, CABG has lower MACE, mortality rates vs. PCI
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Patients with severely reduced left ventricular ejection fraction and CAD who underwent PCI had higher rates of MACE and mortality compared with those who underwent CABG, according to a study published in JAMA Cardiology.
“These benefits were also observed across different patient subgroups including those with left anterior descending-only disease, those who were completely revascularized and those with diabetes,” Louise Y. Sun, MD, SM, assistant professor in the department of anesthesiology, director of Cardiocore Big Data Research Unit and Health Bioinformatics Research and adjunct scientist at the cardiovascular research program at the Institute for Clinical Evaluative Sciences at the University of Ottawa, told Healio.
First revascularization
Researchers analyzed data from 12,113 patients who underwent a first myocardial revascularization procedure in Ontario, Canada, between October 2008 and December 2016. These patients were aged 40 to 84 years, had an LVEF less than 35%, underwent first-time PCI (n = 7,013; mean age, 65 years; 28% women) or isolated CABG (mean age, 66 years; 17% women) and had at least one CAD feature including 70% or greater stenosis in the left anterior descending artery, 50% or greater stenosis in the left main artery or 70% or greater stenosis in two or more major epicardial arteries.
“Evidence is lacking with regard to the optimal treatment strategy for patients with coronary artery disease and severely reduced left ventricular ejection fraction,” Sun said in an interview. “International guidelines differ in recommended strategies for this particular patient group, resulting in wide practice variations across institutions. In the absence of large randomized trials to inform clinical practice, we conducted the largest population-based cohort study to date to compare the long-term outcomes of patients with CAD and reduced LVEF who underwent PCI and CABG.”
The primary outcome of this study was all-cause mortality, with secondary outcomes including CVD death and MACE, defined as subsequent revascularization, stroke or hospitalization for HF or MI. Individual components of MACE were also assessed as the secondary outcome. Follow-up was conducted for a median of 5.2 years.
Researchers performed propensity score matching, which resulted in 2,397 patients who underwent PCI (mean age, 67 years; 21% women) and 2,397 patients who underwent CABG (mean age, 66 years; 20% women).
Compared with patients who underwent CABG, those who underwent PCI had significantly higher rates of CVD death (HR = 1.4; 95% CI, 1.1-1.6), mortality (HR = 1.6; 95% CI, 1.3-1.7) and MACE (HR = 2; 95% CI, 1.9-2.2). This was also observed for individual components of MACE: MI hospitalization (HR = 3.2; 95% CI, 2.6-3.8), HF hospitalization (HR = 1.5; 95% CI, 1.3-1.6) and subsequent revascularization (HR = 3.7; 95% CI, 3.2-4.3).
“Our findings suggest that CABG should be considered as a first-line treatment in patients with CAD and severely reduced LVEF,” Sun told Healio.
In a related editorial, Eric J. Velazquez, MD, Robert W. Berliner Professor of Medicine (Cardiology) and chief of cardiovascular medicine at Yale New Haven Hospital and physician-in-chief of the Heart and Vascular Center at Yale New Haven Health, wrote: “Physician and patient preferences underlying decision-making for revascularization in patients with HF with reduced ejection fraction remain underexplored. For example, as cognitive impairment is common among patients with heart failure and known to worsen after cardiovascular procedures, does the choice of revascularization lead to a differential effect? How does the choice of revascularization procedure affect quality of life? These and other issues must factor into the design of future studies of PCI and CABG in HFrEF that leverage available data in a similar fashion to CorHealth Ontario but minimize confounding by means of randomization, are performed pragmatically and can be generalizable across populations and health systems.” – by Darlene Dobkowski
For more information:
Louise Y. Sun, MD, SM, can be reached at lsun@ottawaheart.ca
Disclosures: The authors report no relevant financial disclosures. Velazquez reports he received personal fees and grants from Novartis.
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