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Despite the plethora of randomized controlled trials comparing coronary artery bypass surgery (CABG) versus percutaneous coronary intervention (PCI), the majority are either underpowered to detect differences in long term mortality, or reflect out of date medical management or stent technologies. Furthermore, randomized studies rarely reflect real world patients. As a result, there is limited data comparing all-comers with multivessel disease (MVD) (including left main), treated with either second generation drug eluting stents (SGS) or CABG.
In this retrospective study we included all patients treated for MVD in Harefield Hospital with either CABG or SGS since 2004. We used Cox regression analysis to present the hazard ratios (HR) for all cause mortality for patients treated with PCI versus those treated with CABG, crudely and after adjustment for confounders.
In this study a total of 6672 patients with MVD were included. Of those 4519 patients underwent CABG whereas 2153 were treated with SGS. Patients treated with surgery were older (66.3±10 vs. 65.3±12.1, p<0.001), more frequently males (81.8% vs. 79.5%), presenting more often with stable coronary artery disease (63.2% vs. 39.1%, p<0.001) and less likely to present in cardiogenic shock (0.8% vs. 3.3%, P<0.001). Surgical patients were less likely to have undergone previous CABG (2.6% vs. 30.3%, p<0.001) or PCI (16.2% vs. 27.4%, p<0.001), but were more likely to have had previous myocardial infarction (44% vs. 33.6%, p<0.001). Prevalence of diabetes (27.4% vs. 24.2%, p=0.006), hypertension (80.2% vs. 58.2%, p<0.001), and previous cerebrovascular accident (6.3% vs. 1.4%, p<0.001) was higher amogst patients receiving a CABG. Presence of severe left ventricular impairment (4.7% vs 8.3%, p<0.001) and current smoking (10.6% vs. 22%, p<0.001) were more prevalent in the PCI group. Surgical patients had more often critical left main stem disease (29.1% vs. 13.4%, p<0.001). In the 1121 (490 to 2160) days of median follow up, 869 (13%) patients died. The age and gender adjusted HR for all cause mortality for patients undergoing PCI vs CABG was 1.72 (95% CI:1.48 to 1.99, p<0.001). After adjustment for all of the above confounders HR remained significantly higher for patients undergoing PCI at 1.38 (95%CI: 1.05 to 1.83, p=0.023).
In the current real-world study CABG appears to offer improved long term survival for patients with MVD. Future large randomized all comer studies are needed to establish the role of multivessel PCI in the contemporary era.
CORONARY: Angioplasty Overview and Outcomes