Therapeutics
Review: CABG reduces long-term mortality and morbidity more than PCI in multivessel coronary disease
Sipahi I, Akay MH, Dagdelen S, Blitz A, Alhan C. Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era. JAMA Intern Med. 2014;174:223-30.
Clinical impact ratings: h ★★★★★✩✩ C ★★★★★★✩ Question
Commentary
In patients with multivessel coronary disease, how do coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) compare for long-term mortality and morbidity?
The meta-analysis by Sipahi and colleagues found a mortality benefit for CABG compared with PCI, with fewer nonfatal coronary events and no increase in stroke. These findings support the use of CABG in this population, but clinical trial results may not fully translate to outcomes in real-world populations where case complexity and referral bias are at play. In addition, the analyses were not stratified by number of diseased vessels or lesion complexity, and few patients with low ejection fraction (EF) were included. The benefits of CABG over PCI are less certain with 2-vessel disease or focal stenoses, whereas the benefit of CABG may be greater or the risks of multivessel PCI higher with complex stenoses or low EF. Consideration of these factors in a patient-level meta-analysis could lead to different conclusions if they are indeed confounding factors. This would be more likely with observational studies than randomized trials, but results of a prior meta-analysis that included data from both observational studies and clinical trials showed a benefit of CABG over PCI regardless of study design (1). An additional concern is use of outdated stent technology in some of the trials. Current secondand third-generation drug-eluting stents with better safety and efficacy profiles could temper the advantage observed for CABG, although this remains to be proven. Further, functional assessment of angiographically intermediate-grade stenoses was not performed; it is unknown how unnecessary revascularization could affect outcomes.
Review scope Included studies compared CABG with PCI in patients with multivessel coronary disease and had a mean follow-up ≥ 1 year. Studies that did not use ≥ 1 arterial graft in ≥ 90% of patients assigned to CABG or did not use stents in ≥ 70% of patients assigned to PCI were excluded. Outcomes were mortality, myocardial infarction (MI), stroke, repeated revascularization, and major adverse cardiac and cerebrovascular events (MACCE).
Review methods MEDLINE, Scopus (including EMBASE/Exerpta Medica), and Cochrane Central Register of Controlled Trials (all to Dec 2012) were searched for published randomized controlled trials (RCTs). 6 RCTs (n = 6055, mean age 60 to 65 y) met the selection criteria. Sample size ranged from 408 to 1900, and mean follow-up ranged from 1 to 6 years (weighted mean 4.1 y).
Main results Meta-analysis showed that CABG reduced risk for mortality, MI, repeated revascularization, and MACCE compared with PCI; groups did not differ for stroke (Table).
Conclusion
Current evidence favors CABG over PCI in patients suitable for either strategy, particularly patients with diabetes. Decision-making becomes more complex for patients with multiple comorbid conditions, less clearly favorable coronary anatomy, or poor renal or cardiac function. Patient preferences and the heart-team approach are crucial for joint decision-making in these patients.
In patients with multivessel coronary disease, CABG reduces long-term mortality and morbidity compared with PCI. Source of funding: No external funding. For correspondence: Dr. I. Sipahi, Acibadem University Medical School, Istanbul, Turkey. E-mail [email protected]. ■ CABG vs PCI in patients with multivessel coronary disease* Outcomes
Number of trials (n)
Weighted event rates CABG PCI
Mortality
6 (6055)
7.3%
Myocardial infarction
5 (5067)
5.4%
Repeated revascularization
6 (6055)
5.8%
MACCE
4 (4659)
Stroke
5 (5067)
16% 3.6%
10% 9.3%
At a weighted mean 4.1 y RRR (95% CI)
NNT (CI)
27% (14 to 38)
38 (27 to 72)
42% (28 to 52)
26 (21 to 39)
20%
71% (59 to 79)
8 (7 to 9)
26%
39% (32 to 46)
10 (9 to 12)
2.6%
RRI (CI)
NNH (CI)
36% (−1 to 86)
Not significant
Ralf E. Harskamp, MD L. Kristin Newby, MD, MHS Duke Clinical Research Institute Durham, North Carolina, USA Reference 1. Takagi H, Yamamoto H, Iwata K, Goto SN, Umemoto T; ALICE (All-Literature Investigation of Cardiovascular Evidence) Group. Drug-eluting stents increase late mortality compared with coronary artery bypass grafting in triple-vessel disease: a meta-analysis of randomized controlled and risk-adjusted observational studies [Letter]. Int J Cardiol. 2012;159:230-3.
*CABG = coronary artery bypass grafting; MACCE = major adverse cardiac and cerebrovascular events; PCI = percutaneous coronary intervention; other abbreviations defined in Glossary. RRR, RRI, NNT, and CI calculated from PCI event rates and risk ratios reported in article.
15 April 2014 | ACP Journal Club | Volume 160 • Number 8
© 2014 American College of Physicians
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/929992/ by a University of California San Diego User on 03/28/2017
JC9
Review: CABG reduces long-term mortality and morbidity more than PCI in multivessel coronary disease
Sipahi I, Akay MH, Dagdelen S, Blitz A, Alhan C. Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era. JAMA Intern Med. 2014;174:223-30.
Clinical impact ratings: h ★★★★★✩✩ C ★★★★★★✩ Question
Commentary
In patients with multivessel coronary disease, how do coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) compare for long-term mortality and morbidity?
The meta-analysis by Sipahi and colleagues found a mortality benefit for CABG compared with PCI, with fewer nonfatal coronary events and no increase in stroke. These findings support the use of CABG in this population, but clinical trial results may not fully translate to outcomes in real-world populations where case complexity and referral bias are at play. In addition, the analyses were not stratified by number of diseased vessels or lesion complexity, and few patients with low ejection fraction (EF) were included. The benefits of CABG over PCI are less certain with 2-vessel disease or focal stenoses, whereas the benefit of CABG may be greater or the risks of multivessel PCI higher with complex stenoses or low EF. Consideration of these factors in a patient-level meta-analysis could lead to different conclusions if they are indeed confounding factors. This would be more likely with observational studies than randomized trials, but results of a prior meta-analysis that included data from both observational studies and clinical trials showed a benefit of CABG over PCI regardless of study design (1). An additional concern is use of outdated stent technology in some of the trials. Current secondand third-generation drug-eluting stents with better safety and efficacy profiles could temper the advantage observed for CABG, although this remains to be proven. Further, functional assessment of angiographically intermediate-grade stenoses was not performed; it is unknown how unnecessary revascularization could affect outcomes.
Review scope Included studies compared CABG with PCI in patients with multivessel coronary disease and had a mean follow-up ≥ 1 year. Studies that did not use ≥ 1 arterial graft in ≥ 90% of patients assigned to CABG or did not use stents in ≥ 70% of patients assigned to PCI were excluded. Outcomes were mortality, myocardial infarction (MI), stroke, repeated revascularization, and major adverse cardiac and cerebrovascular events (MACCE).
Review methods MEDLINE, Scopus (including EMBASE/Exerpta Medica), and Cochrane Central Register of Controlled Trials (all to Dec 2012) were searched for published randomized controlled trials (RCTs). 6 RCTs (n = 6055, mean age 60 to 65 y) met the selection criteria. Sample size ranged from 408 to 1900, and mean follow-up ranged from 1 to 6 years (weighted mean 4.1 y).
Main results Meta-analysis showed that CABG reduced risk for mortality, MI, repeated revascularization, and MACCE compared with PCI; groups did not differ for stroke (Table).
Conclusion
Current evidence favors CABG over PCI in patients suitable for either strategy, particularly patients with diabetes. Decision-making becomes more complex for patients with multiple comorbid conditions, less clearly favorable coronary anatomy, or poor renal or cardiac function. Patient preferences and the heart-team approach are crucial for joint decision-making in these patients.
In patients with multivessel coronary disease, CABG reduces long-term mortality and morbidity compared with PCI. Source of funding: No external funding. For correspondence: Dr. I. Sipahi, Acibadem University Medical School, Istanbul, Turkey. E-mail [email protected]. ■ CABG vs PCI in patients with multivessel coronary disease* Outcomes
Number of trials (n)
Weighted event rates CABG PCI
Mortality
6 (6055)
7.3%
Myocardial infarction
5 (5067)
5.4%
Repeated revascularization
6 (6055)
5.8%
MACCE
4 (4659)
Stroke
5 (5067)
16% 3.6%
10% 9.3%
At a weighted mean 4.1 y RRR (95% CI)
NNT (CI)
27% (14 to 38)
38 (27 to 72)
42% (28 to 52)
26 (21 to 39)
20%
71% (59 to 79)
8 (7 to 9)
26%
39% (32 to 46)
10 (9 to 12)
2.6%
RRI (CI)
NNH (CI)
36% (−1 to 86)
Not significant
Ralf E. Harskamp, MD L. Kristin Newby, MD, MHS Duke Clinical Research Institute Durham, North Carolina, USA Reference 1. Takagi H, Yamamoto H, Iwata K, Goto SN, Umemoto T; ALICE (All-Literature Investigation of Cardiovascular Evidence) Group. Drug-eluting stents increase late mortality compared with coronary artery bypass grafting in triple-vessel disease: a meta-analysis of randomized controlled and risk-adjusted observational studies [Letter]. Int J Cardiol. 2012;159:230-3.
*CABG = coronary artery bypass grafting; MACCE = major adverse cardiac and cerebrovascular events; PCI = percutaneous coronary intervention; other abbreviations defined in Glossary. RRR, RRI, NNT, and CI calculated from PCI event rates and risk ratios reported in article.
15 April 2014 | ACP Journal Club | Volume 160 • Number 8
© 2014 American College of Physicians
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/929992/ by a University of California San Diego User on 03/28/2017
JC9
