CABG outperforms PCI in multivessel disease in real-world cohort with ACS
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In a real-world cohort of Medicare beneficiaries with ACS and multivessel CAD, CABG conferred lower odds of mortality, readmission and repeat procedures compared with PCI, researchers reported.
The researchers analyzed 104,127 Medicare beneficiaries from a CMS database who had initially presented with ACS and were found to have multivessel CAD, and subsequently underwent CABG or multivessel PCI between 2018 and 2020. The findings were presented at the Society of Thoracic Surgeons Annual Meeting.
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“The rationale for this research project started with the 2021 cardiology guidelines on the treatment of coronary artery disease,” J. Hunter Mehaffey, MD, MSc, cardiac surgeon, assistant professor of cardiothoracic surgery and co-director of research in the division of cardiac surgery at West Virginia University, said during a media briefing. “In those guidelines, many cardiac providers were shocked, the indications for CABG in stable multivessel CAD were downgraded from a class IA recommendation to class IIB. Much of this decision ... was based on the guideline committee’s goals to focus on the most recent data, to ensure they were capturing contemporary technology. They only looked at studies going back the past 5 years. Therefore, the guidelines relied heavily on the recently published ISCHEMIA trial, which looked at ... an initial invasive approach compared with an initial conservative approach in patients that had mild to moderate coronary disease, a majority of whom did not qualify for CABG. With the change in the guidelines, we sought to identify a large, contemporary analysis comparing patients undergoing bypass surgery with those undergoing stenting in the modern era with the most recent technology.”
Compared with those who had PCI, those who had CABG were younger (72.9 years vs. 75.2 years; P < .001), had a higher Elixhauser Comorbidity Index (5 vs. 4.2; P < .001) and were more likely to have diabetes (48.5% vs. 42.2%; P < .001), according to the researchers.
CABG was associated with higher cost ($57,189 vs. $36,342; P < .001) and longer length of stay (11.9 days vs. 5.8 days; P < .001).
After inverse probability of treatment weighting adjustment, compared with the PCI group, the CABG group had lower odds of in-hospital mortality (adjusted OR = 0.7; 95% CI, 0.65-0.75; P < .001), hospital admission at 3 years (aOR = 0.77; 95% CI, 0.75-0.8; P < .001), repeat PCI at 3 years (aOR = 0.34; 95% CI, 0.32-0.38; P < .001) and mortality at 3 years (aOR = 0.47; 95% CI, 0.45-0.49; P < .001), according to the researchers.
“The findings of our study are very convincing,” Mehaffey said during the media briefing, noting the CABG group also had lower odds of 30-day and 3-year readmission for MI. “These data demonstrate the importance of assessing longitudinal outcomes to make sure we are making optimal treatment recommendations for our patients. This is a real-world comparison of modern data and is very applicable to patients today. These data put urgency to the need to reevaluate the controversial guidelines to ensure that all patients have access to lifesaving coronary artery surgery.”
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Mehaffey JH, et al. Plenary: J. Maxwell Chamberlain and James S. Tweddell Memorial Papers. Presented at: Society of Thoracic Surgeons Annual Meeting; Jan. 21-23, 2023; San Diego.
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