Percutaneous Coronary Intervention With a Drug-Eluting Stent Versus Coronary Artery Bypass Grafting in Patients Receiving Dialysis: A National Study From Taiwan

Abstract

Rationale & ObjectiveTo study the comparative effectiveness of percutaneous coronary intervention with drug-eluting stent and coronary artery bypass grafting in dialysis patients. Study DesignRetrospective observational cohort study. Setting & ParticipantsThis population-based study identified dialysis patients hospitalized for coronary revascularization between January 1, 2009 and December 31, 2015 in Taiwan National Health Insurance Research Database. ExposuresPercutaneous coronary intervention with drug-eluting stent versus coronary artery bypass grafting. OutcomesAll-cause mortality, in-hospital mortality, and repeat revascularization. Analytical ApproachPropensity scores were used to match patients. Cox proportional hazards models and logistic regression models were constructed to examine associations between revascularization strategies and mortality. Interval Cox models were fit to estimate time-varying hazards during different periods. ResultsA total of 1,840 propensity score-matched dialysis patients were analyzed. Coronary artery bypass grafting was associated with higher in-hospital mortality (coronary artery bypass grafting vs. percutaneous coronary intervention with drug-eluting stent, crude mortality rate 12.5% vs. 3.3%; adjusted odds ratio 5.22; 95% confidence interval [CI] 3.42-7.97; p < 0.001), and longer hospitalization duration (median [interquartile range], 20 [14-30] days vs. 3 [2-8] days, p < 0.001). After discharge, repeat revascularization, acute coronary syndrome, and repeat hospitalization all occurred more frequently in the percutaneous coronary intervention with drug-eluting stent group. Importantly, with a median follow-up of 2.8 years, coronary artery bypass grafting was significantly associated with a higher risk of all-cause overall mortality (adjusted hazard ratio 1.19, 95% CI 1.05-1.35, p = 0.006) in the multivariable Cox proportional hazard model. Sensitivity and subgroup analyses yielded consistent results. LimitationsObservational study with mainly Asian ethnicity. ConclusionsPercutaneous coronary intervention with drug-eluting stent may be associated with better survival than coronary artery bypass grafting in dialysis patients. Future studies are warranted to confirm this finding. Plain Language SummaryAlthough in the general population coronary artery bypass grafting offers better long-term survival than percutaneous coronary intervention with drug-eluting stent, dialysis patients may be too frail to tolerate the increased perioperative mortality risk of coronary artery bypass grafting. In this retrospective study in a national cohort of Taiwan dialysis patients, percutaneous coronary intervention with drug-eluting stent is associated with lower in-hospital mortality and better long-term survival when compared with coronary artery bypass grafting. Subsequent acute coronary syndrome, repeat revascularization, and re-hospitalization developed more frequently in the percutaneous coronary intervention with drug-eluting stent group. These findings may suggest percutaneous coronary intervention with drug-eluting stent as a safe revascularization strategy for dialysis patients.