PCI or CABG in coronary artery disease?

Abstract

In The Lancet today, Mark Hlatky and colleagues 1 Hlatky MA Boothroyd DB Bravata DM et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet. 2009; (published online March 20.)https://doi.org/10.1016/S0140-6736(09)60552-3 Summary Full Text Full Text PDF PubMed Scopus (580) Google Scholar report a pooled analysis of individual data from almost 8000 patients enrolled in ten randomised trials of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) over the past two decades. They conclude that, while at a median 6 years' follow-up there was no overall difference in survival, there was a significant survival advantage with CABG in patients with diabetes (hazard ratio 0·70, 95% CI 0·56–0·87) and in those aged 65 years or older (0·82, 0·70–0·97). Furthermore, the combined endpoint of death or repeat revascularisation was reduced with CABG (10%) compared with PCI (25%; 0·41, 0·37–0·45). Being probably the most definitive and authoritative analyses of the previous randomised trials, these conclusions are important and raise three important questions: are the findings robust; are they consistent with previous reports; and are they generalisable to most patients undergoing PCI or CABG? The last question is particularly relevant to the recent publication of the 1-year interim-analysis of the landmark SYNTAX trial. 2 Serruys PW Morice MC Kappetein AP et al. for the SYNTAX InvestigatorsPercutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009; 360: 961-972 Crossref PubMed Scopus (3178) Google Scholar Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trialsLong-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes. CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups. Full-Text PDF