Long-Term Comparison of Drug-Eluting Stents and Coronary Artery Bypass Grafting for Multivessel Coronary Revascularization

Park, Duk‐Woo; Kim, Young‐Hak; Song, Hae-Geun; Ahn, Jung‐Min; Oh, Jun-Hyok; Kim, Won‐Jang; Lee, Jong‐Young; Kang, Soo–Jin; Lee, Seung-Whan; Lee, Cheol-Whan; Park, Seong-Wook; Yun, Sung‐Cheol; Jung, Sung Ho; Choo, Suk-Jung; Chung, Cheol Hyun; Lee, Jaewon; Park, Seung‐Jung

doi:10.1016/j.jacc.2010.09.022

Cited by 55 publications

(14 citation statements)

References 31 publications

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“…The findings of these studies are consistent with ours because the relative outcomes associated with the two procedures were similar across quartiles [1] or quintiles [17] of PS or terciles of EuroSCORE and SYNTAX Score [4] . The categorization adopted in these studies may, however, have been too broad to unveil the heterogeneity of treatment-effect estimates [18,19] , while the one adopted here should yield stronger evidence.…”

Section: Discussionsupporting

confidence: 87%

“…In the case of severe Coronary Artery Disease (CAD) (left main or multivessel involvement) -the scientific evidence [1][2][3][4][5][6][7][8][9] supporting the interventional choice between Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft (CABG) is inconclusive. Uncertainty surrounds not only the 'best' technique in absolute terms (i.e.…”

mentioning

confidence: 99%

“…Notwithstanding this, tailoring the choice to the patient's characteristics is often advocated as important for outcome optimization [4] , as if the clinicians' judgment could attain what the literature has not yet demonstrated.…”

mentioning

confidence: 99%

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Description of a methodological approach to verify the outcome-optimization of tailored therapeutic choices and test application to PCI vs. CABG.

Bartolomeo

Guastaroba

Fortuna

et al. 2012

JHA

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Background: The scientific evidence guiding the choice between Percutaneous Coronary Intervention (PCI) and Bypass Graft Surgery (CABG) is inconclusive. Yet, tailoring the choice to the patients' characteristics is generally considered important to optimize outcomes. Objectives:To verify the supposed outcome benefits of tailoring the choice of the revascularization procedure. Methods:We calculated a propensity score (PS) -i.e. the probability, given the patients' characteristics, of undergoing one of the two alternative procedures -for the 11,750 patients with severe coronary disease who underwent coronary revascularization between 2002 and 2008 in an Italian region. Then we investigated the effect-modification of the PS on the Hazard Ratios (HR) of PCI vs. CABG for death, myocardial infarction, stroke and repeat revascularization with a likelihood ratio test and by visual inspection. Results:Only the least important outcome (repeat revascularization) significantly differed across deciles of PS (p=0.05) and its graphical trend supported a favorable effect of the decision process. Conclusions:In agreement with the current scientific uncertainty, but contrary to common opinion, the medical decision process between PCI and CABG based on demographic and clinical factors is marginally capable of optimizing the post-procedural outcomes. The study relies on the assumption that the variables considered by clinicians were among those included in the PS.

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Section: Discussionsupporting

confidence: 87%

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confidence: 99%

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Description of a methodological approach to verify the outcome-optimization of tailored therapeutic choices and test application to PCI vs. CABG.

Bartolomeo

Guastaroba

Fortuna

et al. 2012

JHA

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“…1,[7][8][9][10] Clinical registry and trials data have shown a repeat revascularization rate of ≈5% at 5 years after surgery, 10 but these prior studies were limited in size, types of centers, and duration of follow-up. 1,7,8,10,11 Over an 18-year time frame, the present study was able to document a low rate of repeat revascularization after CABG among patients aged ≥65 years. Fewer than 10% of CABG patients required a repeat revascularization procedure within 5 years and 13% within 10 years; only 1 in 6 patients who survived 18 years underwent a repeat procedure.…”

Section: Discussionmentioning

confidence: 99%

Repeat Coronary Revascularization After Coronary Artery Bypass Surgery in Older Adults

et al. 2013

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Background-A major advantage of coronary artery bypass graft surgery (CABG) relative to percutaneous coronary intervention is its durability, yet there is a paucity of information on rates and predictors of repeat coronary revascularization after CABG in the modern era. Methods and Results-We included patients ≥65 years from the Society of Thoracic Surgeons' National Adult Cardiac Surgery Database who were undergoing first-time isolated CABG from 1991 to 2007 (n=723 134, median age 73 years). After linking to Medicare claims data, long-term outcomes of CABG (up to 18 years after surgery) were examined by use of cumulative incidence curves. Multivariable Cox proportional hazard analysis was used to identify factors associated with 1-and 5-year repeat revascularization trends and variability. We found that the overall 18-year survival rate was 20%. Cumulative incidences of any repeat revascularization (percutaneous coronary intervention or CABG, yet most often percutaneous coronary intervention) were 2%, 7%, 13%, and 16% at 1, 5, 10, and 18 years after surgery, respectively. The rates of repeat CABG procedures were quite low for all time points (0.1%, 0.6%, 1.3%, and 1.7%, respectively). Female sex, disease severity represented by a history of percutaneous coronary intervention, preoperative dialysis, and partial revascularization were strongly associated with a higher revascularization rate, whereas advanced age, left main disease, and smoking were associated with a lower rate. There was approximately a 2-fold variation in repeat revascularization rates across centers at 1 year (interquartile range 1.7-3.6%) and 5 years (interquartile range 6.7-12.0%). Conclusions-Repeat revascularization is performed infrequently among older patients who undergo CABG; however, these rates vary substantially by patient subgroups and among providers.

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“…In summary, data from SYNTAX and CARDia and from nonrandomized comparisons [21,22] demonstrate equivalent short-term mortality of PCI with DES and CABG in patients with diabetes, except for patients with the most complex disease (SYNTAX score ≥33) [19]. Importantly, follow-up at 1-year may not yet reflect the true long-term differences between CABG and DES treatment of patients with DM because previous reports demonstrated reduced long-term mortality in CABG compared with PCI [17,18].…”

Section: Cabg Versus Pci In Multivessel Cadmentioning

confidence: 99%

Role of CABG in the management of obstructive coronary arterial disease in patients with diabetes mellitus

Aronson

Edelman

2012

Current Opinion in Pharmacology

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Multiple studies have shown that diabetes mellitus (DM) can affect the efficacy of revascularization therapies and subsequent clinical outcomes. Selection of the appropriate myocardial revascularization strategy is critically important in the setting of multivessel coronary disease. Optimal medical therapy is an appropriate first-line strategy in patients with DM and mild symptoms. When medical therapy does not adequately control symptoms, revascularization with either PCI or CABG may be used. In patients with treated DM, moderate to severe symptoms and complex multivessel coronary disease, coronary artery bypass graft surgery provides better survival, fewer recurrent infarctions and greater freedom from re-intervention. Decisions regarding revascularization in patients with DM must take into account multiple factors and as such require a multidisciplinary team approach (‘heart team’).

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Long-Term Comparison of Drug-Eluting Stents and Coronary Artery Bypass Grafting for Multivessel Coronary Revascularization

Abstract: For patients with multivessel disease, DES treatment, compared with CABG, showed similar rates of mortality and of the composite safety outcomes, but higher rates of revascularization up to 5 years.

Cited by 55 publications

References 31 publications

Description of a methodological approach to verify the outcome-optimization of tailored therapeutic choices and test application to PCI vs. CABG.

Description of a methodological approach to verify the outcome-optimization of tailored therapeutic choices and test application to PCI vs. CABG.

Repeat Coronary Revascularization After Coronary Artery Bypass Surgery in Older Adults

Role of CABG in the management of obstructive coronary arterial disease in patients with diabetes mellitus

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