In all-comers registry of left main CAD, CABG linked to better survival vs. PCI
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BOSTON — In the all-comers SCAAR registry of patients with left main CAD who underwent revascularization in Sweden, PCI was associated with higher mortality rates compared with CABG.
The analysis, presented at TCT 2022, included all patients with left main CAD with at least 50% stenosis and stable angina, unstable angina or non-STEMI who underwent PCI or CABG in Sweden from 2015 to 2022. Patients with STEMI and those ineligible for surgery were excluded.
The cohort included 10,254 patients, 52.6% of whom had PCI, who were revascularized at one of 30 hospitals in Sweden, and the hospitals varied greatly in how often they perform PCI vs. CABG in this population, Elmir Omerovic, MD, PhD, FESC, professor of cardiology at Sahlgrenska University Hospital in Gothenburg, Sweden, said during a press conference.
“There are few trials that have compared CABG and PCI when it comes to the treatment of left main coronary artery disease,” Omerovic said during the press conference. “It remains unclear whether revascularization by PCI is noninferior to CABG. We wanted to compare PCI vs. CABG in a real-life patient population in our registry.”
He noted PCI became more widely used during the study period.
In the PCI group, the mean age was 74 years and 81% were men. In the CABG group, the mean age was 70 years and 79% were men.
“We used a treatment preference instrument, which was defined as quintiles of preference for PCI at the different hospitals” for the analysis, Omerovic said. “In addition to that, we accounted for other known confounders. The treatment preference instrument works as an act of randomization.”
There was higher risk for the primary outcome of all-cause mortality in the PCI group compared with the CABG group (adjusted HR = 1.59; 95% CI, 1.11-2.27; P = .011), Omerovic said during the press conference.
He said patients older than 80 years had lower mortality with PCI as opposed to CABG, but the opposite was true in patients aged 80 years or younger (P for interaction < .05).
“I would say to surgeons, do not operate on high-risk elderly patients,” Omerovic said.
The expected survival benefit with CABG was more pronounced in patients with longer life expectancy than in those with shorter life expectancy, he said during the press conference.
“In our observational study, CABG was associated with lower mortality risk in patients with left main CAD,” Omerovic said.
In a discussion during the press conference, Roxana Mehran, MD, professor of medicine and director of interventional cardiovascular research and clinical trials at the Zena and Michael A. Weiner Cardiovascular Institute at the Icahn School of Medicine at Mount Sinai, said, “I think what we’re seeing with the interaction for age is that an elderly patient is going to have less time to live, and we have to consider that when we imagine how these data are translatable. ”
Perspective
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We have conflicting data sometimes. I take registry data as hypothesis-generating. I don’t think it can or should inform our decisions to a large extent, except for some things that also make biological sense; for example, the higher risk identified in the SCAAR registry for CABG in those older than age 80. I would advocate for registry-based randomized trials, especially when there is equipoise. In my opinion, it is an ethical mandate that we continue to study to bring the best therapies to patients. We make decisions every day that are in a sense allocating patients to different groups. These registries allow for very good options in terms of getting randomized real-world data with patient consent.
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Omerovic E, 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).
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