BEST: Few differences in long-term outcomes between PCI, CABG in multivessel CAD
BOSTON — At a median follow-up of 11.8 years, most outcomes did not differ between PCI with an everolimus-eluting stent and CABG in patients with multivessel CAD, according to new data from the BEST trial.
However, spontaneous MI and repeat revascularization occurred more frequently in the PCI group, researchers reported at TCT 2022.
As Healio previously reported, in the main results of BEST, published in 2015 in The New England Journal of Medicine, at a median follow-up of 4.8 years, the primary endpoint of death, MI or target vessel revascularization was higher in the group that had PCI with an EES (Xience, Abbott Vascular) than in the CABG group.
“[Afterward], we performed an extended clinical follow-up to evaluate longer-term comparative outcomes between PCI with everolimus-eluting stents and CABG among patients with multivessel coronary artery disease, who were followed for up to 13.7 years after initial enrollment in the BEST trial,” Jung-Min Ahn, MD, PhD, associate professor at Asan Medical Center, Ulsan University College of Medicine, Seoul, South Korea, said during a press conference.
The present analysis, simultaneously published in Circulation, included 880 patients (mean age, 64 years; 71% men). In the PCI group, 71.8% had IVUS guidance and 50.9% had complete revascularization, and in the CABG group, 71.5% had complete revascularization, Ahn said during the press conference.
In the extended follow-up (median, 11.8 years) analysis, the primary endpoint occurred in 34.5% of the PCI group and 30.3% of the CABG group (HR = 1.18; 95% CI, 0.88-1.56; P = .26), Ahn said.
He said there were also no differences between the groups in death/MI/stroke (HR = 1.07; 95% CI, 0.75-1.53; P = .7) or in all-cause mortality (HR = 1.04; 95% CI, 0.65-1.67; P = .86).
However, Ahn said, the PCI group had higher rates of spontaneous MI (7.1% vs. 3.8%; HR = 1.86; 95% CI, 1.06-3.27; P = .031) and repeat revascularization of any kind (22.6% vs. 12.7%; HR = 1.92; 95% CI, 1.58-2.32; P < .001).
In addition, when the PCI group was stratified by whether they had IVUS during their procedure, those that had IVUS had similar rates of the primary outcome and of all-cause mortality to the CABG group, but those who did not have IVUS had higher rates than the CABG group (log-rank P for primary outcome < .001; log-rank P for all-cause mortality = .08), according to the researchers.
“The extended follow-up of the BEST trial provides important long-term insights that could aid in the decision-making for the optimal revascularization strategy in patients with multivessel coronary artery disease,” Ahn said during the press conference.
References:
- Ahn JM, et al. Circulation. 2022;doi:10.1161/CIRCULATIONAHA.122.062188.
- Park SJ, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1415447.
Perspective
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The gold standard remains randomized clinical trials. We need to make them more inclusive to apply to a bigger population. Randomized trials, of which BEST is one, are important because they eliminate selection bias. With that in mind, the results are reassuring that the differences are not great between CABG and PCI in this population.
At the end of the day, coronary disease is a complex disease. We have to be careful in this regard and should tailor the therapy to individual patients, when we have options, and use shared decision-making, which of course includes the patient. At lot of the decision-making is based on anatomy. Is the artery ideal for grafting? Are the lesions proximal or distal? Is there a good target to put the graft in? How many lesions are there? The SYNTAX score and the other scores we have do not capture everything, so I do think there is a role for clinical judgment and a good interpretation of the angiogram. We try to do that on a daily basis.
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Ahn JM, et al. Late-Breaking Clinical Science in Coronary Artery Disease: Session V, in Collaboration With The Lancet. Presented at: TCT Scientific Symposium; Sept. 16-19, 2022; Boston (hybrid meeting).