Evidence-Based Medicine Online First, published on July 3, 2015 as 10.1136/ebmed-2015-110211
Therapeutics/Prevention
Randomised controlled trial
Coronary artery bypass surgery continues to remain the treatment of choice for multivessel coronary artery disease even in the era of new-generation drug-eluting stents 10.1136/ebmed-2015-110211
Friedrich W Mohr, Piroze M Davierwala Department of Cardiac Surgery, Herzzentrum, Leipzig, Germany Correspondence to: Dr Friedrich W Mohr, Department of Cardiac Surgery, Herzzentrum, Struempellstrasse 39, Leipzig 04289, Germany; [email protected]
Commentary on: Park SJ, Ahn JM, Kim YH, et al; BEST Trial Investigators. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med 2015;372:1204–12.
Context Multivessel coronary artery disease (MVCAD) may be found in patients subjected to coronary angiography. It is treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). The expanded use of PCI, following development of drug-eluting stents (DES), necessitated comparison of its outcomes with CABG (gold standard therapy). The SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) trial favoured CABG with regard to occurrence of cardiac death, myocardial infarction (MI), repeat revascularisation, and major cardiac and cerebrovascular events.1 New-generation DES and new antiproliferative agents have better efficacy and safety than first-generation DES,2 thus entailing comparison studies with CABG.
Commentary This study corroborates the results of the SYNTAX trial,1 albeit in the era of new-generation DES, and conforms well to other data.3–6 The higher spontaneous MI and repeat revascularisation rates with PCI could be due to stent thrombosis (ST), in-stent restenosis, disease progression or incomplete revascularisation. ST and in-stent restenosis have been considerably minimised with the use of new-generation DES.2 In the present study, ST was observed in only 1.6% of patients causing only one fatal MI. Target lesion revascularisation rates were similar between treatment groups, suggestive of low in-stent restenosis rates. However, the higher rates of any repeat revascularisation may be due to distal disease progression in the target vessel, which could explain higher target-vessel revascularisation rates in the PCI group. Whether PCI will ever supersede CABG in treatment of advanced MVCAD is debatable. This is because bypass grafts provide protection against future development and progression of disease. Incomplete revascularisation, which was more commonly seen in the PCI group, could also produce spontaneous MI. A study that compared CABG and PCI (with EES), demonstrated that incomplete revascularisation with PCI was associated with a significantly higher risk of MI ( p=0.02 for interaction).3 Incomplete revascularisation with PCI is often due to inability to negotiate a complex lesion in a vessel supplying a significant myocardial area. During CABG, non-grafted vessels are frequently fibrotic, diffusely diseased or extremely small. Non-revascularisation of such vessels produces no adverse clinical or pathological consequences. The findings of this trial may not be universally applicable as it was small and 33) or a high-risk profile (EuroSCORE>6). The CABG group had a significantly higher rate of complete revascularisation than the PCI group (71.5% vs 50.9%, p
Therapeutics/Prevention
Randomised controlled trial
Coronary artery bypass surgery continues to remain the treatment of choice for multivessel coronary artery disease even in the era of new-generation drug-eluting stents 10.1136/ebmed-2015-110211
Friedrich W Mohr, Piroze M Davierwala Department of Cardiac Surgery, Herzzentrum, Leipzig, Germany Correspondence to: Dr Friedrich W Mohr, Department of Cardiac Surgery, Herzzentrum, Struempellstrasse 39, Leipzig 04289, Germany; [email protected]
Commentary on: Park SJ, Ahn JM, Kim YH, et al; BEST Trial Investigators. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med 2015;372:1204–12.
Context Multivessel coronary artery disease (MVCAD) may be found in patients subjected to coronary angiography. It is treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). The expanded use of PCI, following development of drug-eluting stents (DES), necessitated comparison of its outcomes with CABG (gold standard therapy). The SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) trial favoured CABG with regard to occurrence of cardiac death, myocardial infarction (MI), repeat revascularisation, and major cardiac and cerebrovascular events.1 New-generation DES and new antiproliferative agents have better efficacy and safety than first-generation DES,2 thus entailing comparison studies with CABG.
Commentary This study corroborates the results of the SYNTAX trial,1 albeit in the era of new-generation DES, and conforms well to other data.3–6 The higher spontaneous MI and repeat revascularisation rates with PCI could be due to stent thrombosis (ST), in-stent restenosis, disease progression or incomplete revascularisation. ST and in-stent restenosis have been considerably minimised with the use of new-generation DES.2 In the present study, ST was observed in only 1.6% of patients causing only one fatal MI. Target lesion revascularisation rates were similar between treatment groups, suggestive of low in-stent restenosis rates. However, the higher rates of any repeat revascularisation may be due to distal disease progression in the target vessel, which could explain higher target-vessel revascularisation rates in the PCI group. Whether PCI will ever supersede CABG in treatment of advanced MVCAD is debatable. This is because bypass grafts provide protection against future development and progression of disease. Incomplete revascularisation, which was more commonly seen in the PCI group, could also produce spontaneous MI. A study that compared CABG and PCI (with EES), demonstrated that incomplete revascularisation with PCI was associated with a significantly higher risk of MI ( p=0.02 for interaction).3 Incomplete revascularisation with PCI is often due to inability to negotiate a complex lesion in a vessel supplying a significant myocardial area. During CABG, non-grafted vessels are frequently fibrotic, diffusely diseased or extremely small. Non-revascularisation of such vessels produces no adverse clinical or pathological consequences. The findings of this trial may not be universally applicable as it was small and 33) or a high-risk profile (EuroSCORE>6). The CABG group had a significantly higher rate of complete revascularisation than the PCI group (71.5% vs 50.9%, p
