Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease

Serruys, Patrick W.; Unger, Felix; Sousa, J. Eduardo; Jatene, Adib; Bonnier, Hans; Schönberger, Jacques P.A.M.; Buller, Nigel; Bonser, Robert S.; Brand, Moshe; Herwerden, Lex A. van; Morel, Marie‐Angèle; Hout, Ben A. van

doi:10.1056/nejm200104123441502

Cited by 996 publications

(369 citation statements)

References 34 publications

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“…MI was adjudicated according to the definition in the Arterial Revascularization Therapy Study. 21 Within 1 week of the index procedure, only Q-wave MI was adjudicated as MI. Stroke at follow-up was defined as symptomatic stroke.…”

Section: Clinical End Points and Data Collection For Followup Eventsmentioning

confidence: 99%

Very Long–Term (10 to 14 Year) Outcomes After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease in the Bare-Metal Stent Era

Shiomi

Yamaji

Morimoto

et al. 2016

Circ: Cardiovascular Interventions

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Background— Many of the previous randomized trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease reported equivalent or better survival with CABG as compared with PCI at 5-year follow-up. However, 5-year follow-up might be too short to evaluate the true differences in long-term clinical outcomes between PCI and CABG. Methods and Results— Among 8934 patients enrolled in the extended 10- to 14-year follow-up study of the CREDO-Kyoto registry cohort-1 (Coronary Revascularization Demonstrating Outcome study in Kyoto) conducted in the bare-metal stent era, 5152 (PCI: n=3490 and CABG: n=1662) patients had multivessel coronary artery disease without left main disease. Median follow-up duration was 11.2 (interquartile range: 10.2–12.2) years. The cumulative 10-year incidence of all-cause death was not significantly different between PCI and CABG (32.2% versus 31.7%; log-rank P =0.93). After adjusting for confounders, however, the mortality risk of PCI was significantly higher than that of CABG (hazard ratio, 1.19 [95% confidence interval, 1.02–1.39]; P =0.03). Within 5 years after the index procedure, the risk for all-cause death was significantly higher after PCI than after CABG (hazard ratio, 1.41; 95% CI, 1.12–1.79; P =0.004). By a landmark analysis at 5 years, however, the cumulative 10-year incidence of and adjusted risk for all-cause death beyond 5 years were not significantly different between PCI and CABG (19.3% versus 20.0%; log-rank P =0.22 and hazard ratio, 1.02, 95% confidence interval, 0.83–1.26; P =0.82). Conclusions— CABG as compared with PCI was associated with better 10-year survival in patients with multivessel coronary artery disease. However, the benefit of CABG compared with PCI on late mortality beyond 5 years was not observed in this study.

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Section: Clinical End Points and Data Collection For Followup Eventsmentioning

confidence: 99%

Very Long–Term (10 to 14 Year) Outcomes After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease in the Bare-Metal Stent Era

Shiomi

Yamaji

Morimoto

et al. 2016

Circ: Cardiovascular Interventions

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“…Third, other issues such as operative mortality and morbidity considerations and longer length of stay with CABG can also be important considerations. 13 Finally, most of the randomized controlled trials comparing PCI with CABG enrolled highly selected stable CAD patients who were considered suitable candidates for either procedure and who were free from major comorbidities that would be expected to preclude long-term survival.…”

Section: Discussionmentioning

confidence: 99%

“…8 These recommendations are based largely on randomized control trials enrolling patients with stable CAD. [9][10][11][12][13] However, in a subgroup analysis of the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial, in which approximately one third of the cohort (n=583) was enrolled after an ACS event, the superiority of CABG in the ACS subset was comparable to the overall trial population. 11 Despite the guideline recommendations favoring CABG, previous studies have identified an implementation gap between the available evidence base and routine medical practice in patients with DM, with at least 1 in 4 eligible patients with multivessel CAD receiving PCI instead of CABG.…”

mentioning

confidence: 99%

Revascularization Trends in Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease Presenting With Non–ST Elevation Myocardial Infarction

Pandey

McGuire

Lemos

et al. 2016

Circ: Cardiovascular Quality and Outcomes

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Background-Current guidelines recommend surgical revascularization (coronary artery bypass graft [CABG]) over percutaneous coronary intervention (PCI) in patients with diabetes mellitus and multivessel coronary artery disease. Few data are available describing revascularization patterns among these patients in the setting of non-ST-segment-elevation myocardial infarction. Methods and Results-Using Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (ACTION Registry-GWTG), we compared the in-hospital use of different revascularization strategies (PCI versus CABG versus no revascularization) in diabetes mellitus patients with non-ST-segment-elevation myocardial infarction who had angiography, demonstrating multivessel coronary artery disease between July 2008 and December 2014. Factors associated with use of CABG versus PCI were identified using logistic multivariable regression analyses. A total of 29 769 patients from 539 hospitals were included in the study, of which 10 852 (36.4%) were treated with CABG, 13 760 (46.2%) were treated with PCI, and 5157 (17.3%) were treated without revascularization. The overall use of revascularization increased over the study period with an increase in the proportion undergoing PCI (45% to 48.9%; P trend =0.0002) and no change in the proportion undergoing CABG (36.1% to 34.7%; p trend =0.88). There was significant variability between participating hospitals in the use of PCI and CABG (range: 22%-100%; 0%-78%, respectively; P value <0.0001 for both). Patient-level, but not hospital-level, characteristics were statistically associated with the use of PCI versus CABG, including anatomic severity of the disease, early treatment of adenosine diphosphate receptor antagonists at presentation, older age, female sex, and history of heart failure. Conclusions-Among patients with diabetes mellitus and multivessel coronary artery disease presenting with non-ST-segment-elevation myocardial infarction, only one third undergo CABG during the index admission. Furthermore, the use of PCI, but not CABG, increased modestly over the past 6 years. (Circ Cardiovasc Qual Outcomes. 2016;9:197-205.

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“…In the field of ischemic heart disease, many trials examine the impact of therapy on combined clinical outcomes, including cardiovascular death, myocardial infarction (MI), stroke, unstable angina (UA) admissions, and revascularization procedures 3, 4, 5, 6, 7. Although the clinical impact of the first 3 events are of uncontested importance, it remains unclear whether nonfatal events, such as UA and coronary revascularizations, are individually associated with subsequent survival and warrant inclusion as a component of major adverse cardiovascular events (MACE).…”

Section: Introductionmentioning

confidence: 99%

“…For example, in trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting for multivessel coronary artery disease, many demonstrate that the use of coronary artery bypass grafting, as compared with PCI, results in lower rates of MACE, mainly attributed to a higher rate of repeat revascularization with PCI. Given that these studies typically show no differences in hard end points (eg, mortality), but may be of insufficient duration for the full mortality benefit to be realized, more data on the long‐term prognostic significance of different MACE components are needed 5, 6, 7…”

Section: Introductionmentioning

confidence: 99%

Prognostic Impact of Subsequent Acute Coronary Syndrome and Unplanned Revascularization on Long‐Term Mortality After an Index Percutaneous Coronary Intervention: A Report From a Japanese Multicenter Registry

Inohara

Kohsaka

Matsubara

et al. 2017

JAHA

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BackgroundWhereas composite end points are often used in clinical trials of percutaneous coronary interventions (PCI), the impact of individual components on subsequent survival is incompletely defined. We evaluated the association of subsequent acute coronary syndromes (ACS) and unplanned coronary revascularization post‐PCI with long‐term survival.Methods and ResultsFrom 2009 to 2011, the KiCS‐PCI (Keio interhospital Cardiovascular Studies) consecutively enrolled patients undergoing PCI in 14 Japanese teaching hospitals. We identified patients who experienced ACS or unplanned coronary revascularization following their index PCI and compared subsequent survival during the 2‐year follow‐up period using propensity‐matched cohorts of patients who did and did not experience these events. Cox proportional hazard models were used to assess 2‐year all‐cause mortality. Because unstable angina is less severe than acute myocardial infarction, we also generated a separate propensity‐matched cohort for UA post‐PCI. Among 3348 PCI patients (mean age, 67.5±10.7 years; 79.7% male), 214 (6.4%) experienced a subsequent ACS (168 events [78.5%] were unstable angina), and 198 (5.9%) underwent unplanned revascularization. In the propensity‐matched cohorts, patients with a subsequent ACS admission had an increased risk of mortality as compared with those without (hazard ratio, 4.73; 95% confidence interval=1.35–16.6; P=0.015), whereas those with an unplanned revascularization did not have significantly higher risk (hazard ratio, 2.97; 95% confidence interval=0.57–14.3; P=0.19). Among unstable angina events, no association with mortality was observed (hazard ratio, 1.39; 95% confidence interval=0.48–4.00; P=0.54).ConclusionsIn the KiCS‐PCI registry, the incidence of a subsequent ACS was associated with higher mortality, but this association was less apparent after unplanned coronary revascularization or unstable angina. The prognostic implications of different outcomes in a composite end point should be considered when interpreting the results of clinical trials in PCI.

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Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease

Cited by 996 publications

References 34 publications

Very Long–Term (10 to 14 Year) Outcomes After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease in the Bare-Metal Stent Era

Very Long–Term (10 to 14 Year) Outcomes After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease in the Bare-Metal Stent Era

Revascularization Trends in Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease Presenting With Non–ST Elevation Myocardial Infarction

Prognostic Impact of Subsequent Acute Coronary Syndrome and Unplanned Revascularization on Long‐Term Mortality After an Index Percutaneous Coronary Intervention: A Report From a Japanese Multicenter Registry

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