Author + information
- Received September 15, 2017
- Revision received October 5, 2017
- Accepted October 17, 2017
- Published online December 18, 2017.
- Suzanne J. Baron, MD, MSca,
- Khaja Chinnakondepalli, MSa,
- Elizabeth A. Magnuson, ScDa,
- David E. Kandzari, MDb,
- John D. Puskas, MDc,
- Ori Ben-Yehuda, MDd,
- Gerrit-Anne van Es, PhDe,
- David P. Taggart, MDf,
- Marie-Claude Morice, MDg,
- Nicholas J. Lembo, MDc,
- W. Morris Brown III, MDc,
- Adrian Banning, MDf,
- Charles A. Simonton, MDh,
- A. Pieter Kappetein, MD, PhDi,
- Joseph F. Sabik, MDj,
- Patrick W. Serruys, MD, PhDk,
- Gregg W. Stone, MDd,l,
- David J. Cohen, MD, MSca,∗ (, )
- on behalf of the EXCEL Investigators
- aSaint Luke’s Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- bPiedmont Heart Institute, Atlanta, Georgia
- cMount Sinai Medical Center, New York, New York
- dCardiovascular Research Foundation, New York, New York
- eCardialysis, Rotterdam, the Netherlands
- fOxford University Hospitals, Oxford, United Kingdom
- gRamsay Générale de Santé, Hospital Privé Jacques Cartier, Massy, France
- hAbbott Vascular Inc., Abbott Park, Illinois
- iErasmus Medical Center, Rotterdam, the Netherlands
- jCleveland Clinic Foundation, Cleveland, Ohio
- kInternational Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- lNew York-Presbyterian Hospital, Columbia University Medical Center, New York, New York
- ↵∗Address for correspondence:
Dr. David J. Cohen, Saint-Luke’s Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, 4401 Wornall Road, Kansas City, Missouri 64111.
Background The EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial compared outcomes in patients with unprotected left main coronary artery disease (LMCAD) treated with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) using everolimus-eluting stents. Whereas rates of death, stroke, and myocardial infarction were similar at 36 months, event timing and repeat revascularization rates differed by treatment group.
Objectives To understand the effects of revascularization strategy from the patient’s perspective, a prospective quality of life (QoL) substudy was performed alongside the EXCEL trial.
Methods Between September 2010 and March 2014, 1,905 patients with LMCAD were randomized to undergo CABG or PCI, of whom 1,788 participated in the QoL substudy. QoL was assessed at baseline and 1, 12, and 36 months using the Seattle Angina Questionnaire, the 12-Item Short Form Health Survey, the Rose Dyspnea Scale, the Patient Health Questionnaire-8, and the EQ-5D. Differences between PCI and CABG were assessed using longitudinal random-effect growth curve models.
Results Over 36 months, both PCI and CABG were associated with significant improvements in QoL compared with baseline. At 1 month, PCI was associated with better QoL than CABG. By 12 months though, these differences were largely attenuated, and by 36 months, there were no significant QoL differences between PCI and CABG.
Conclusions Among selected patients with LMCAD, both PCI and CABG result in similar QoL improvement through 36 months, although a greater early benefit is seen with PCI. Taken together with the 3-year clinical results of EXCEL, these findings suggest that PCI and CABG provide similar intermediate-term outcomes for patients with LMCAD. (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776)
Over the last several years, percutaneous coronary intervention (PCI) using drug-eluting stents (DES) has emerged as an alternative to coronary artery bypass graft surgery (CABG) for revascularization of patients with left main coronary artery disease (LMCAD) (1–3). European and U.S. guidelines currently provide Class IIa recommendations for PCI in the treatment of appropriately selected patients with LMCAD of low anatomical complexity (4,5). Since those guidelines were published, the large-scale, randomized EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial demonstrated similar rates of death, stroke, and myocardial infarction (MI) at a median of 36 months in patients with LMCAD who were randomized to either CABG or PCI with a second-generation everolimus-eluting stent (6). Nevertheless, the 2 treatments did differ in certain respects. First, compared with PCI, the CABG group was more likely to experience an MI within the first 30 days. Conversely, the rate of repeat revascularization was significantly higher in the PCI group by 36 months.
Given similar rates of irreversible long-term clinical outcomes, other factors including patient-reported health status should be considered when choosing a revascularization strategy for a patient with LMCAD. Prior studies have demonstrated that patients with multivessel CAD treated with CABG have greater angina relief in the long run when compared with patients treated with PCI (7–9). However, these studies used first-generation DES, which have been shown to have an inferior safety and efficacy profile compared with contemporary DES. Furthermore, these studies were not limited to patients with LMCAD, which is an anatomically distinct population that has been relatively understudied in terms of patient-reported outcomes. As such, whether differences between PCI and CABG regarding the timing of certain events (e.g., stroke and MI) and completeness of revascularization result in differences in health status in patients with LMCAD treated with PCI versus CABG in the contemporary era is unknown. To more fully understand the effects of each revascularization strategy from the patient’s perspective, we performed a prospective study alongside the EXCEL trial to compare both short- and long-term health status outcomes in patients with LMCAD treated with PCI or CABG.
The design of the EXCEL trial has been described previously (6,10). Briefly, the EXCEL trial enrolled 1,905 LMCAD patients at 126 sites in 17 countries between September 2010 and March 2014. Inclusion criteria were LM coronary artery stenosis ≥70% as estimated visually or 50% to 70% with invasive or noninvasive testing suggesting hemodynamic significance. Patients were also required to have anatomical disease of low-to-intermediate complexity (defined as a site-determined SYNTAX [Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery] score ≤32) and to be considered appropriate for either CABG or PCI by a local heart team that included an interventional cardiologist and a cardiac surgeon (11). Patients were then randomized 1:1 to revascularization by either CABG or PCI using a second-generation everolimus-eluting stent (Xience, Abbott Vascular, Santa Clara, California) and followed for 5 years. All patients provided written informed consent, and the trial was approved by the institutional review board at each site.
Measurement of health status
Health status was assessed at baseline and at 1 month, 12 months, and 36 months after randomization. Baseline questionnaires were completed at the time of study enrollment under the supervision of a trained research assistant. Follow-up health status was assessed using self-administered written questionnaires at follow-up clinic visits. For those patients who were unable to complete the questionnaires in person (<5%), telephone-based follow-up was permitted. Disease-specific health status was assessed using the Seattle Angina Questionnaire (SAQ) and the Rose Dyspnea Scale (RDS). The SAQ is a validated 19-item questionnaire that assesses 5 key domains of health status in patients with CAD (angina frequency, physical limitations, quality of life [QoL], angina stability, and treatment satisfaction) and is scored from 0 to 100 with higher scores indicating less symptoms and better health status (12,13). Changes of 8 to 10 points in the SAQ subscales have been demonstrated to be clinically meaningful to the individual patient (13).
The RDS is a 4-item questionnaire that assesses a patient’s level of dyspnea with activity. Scores range from 0 to 4, with 0 indicating no dyspnea and 4 indicating dyspnea with minimal activity. Prior studies have demonstrated the validity of the RDS in patients treated with PCI (14) and have shown that higher RDS scores are associated with a greater risk of rehospitalization and poorer survival in this population (15). Since the RDS is an ordinal scale, a 1-unit change would be considered clinically important for an individual patient.
Generic health status was evaluated by means of the 12-Item Short Form Health Survey (SF-12) (16), the Patient Health Questionnaire-8 (PHQ-8) (17), and the EQ-5D (18). SF-12 is derived from the Medical Outcomes Study Short-Form 36 and provides physical and mental component summary scores, which are scaled such that the mean score in the U.S. population is 50 with a standard deviation of 10, with higher scores representing better health status. The minimum clinically important difference for the SF-12 summary scores is ∼2 points (19).
The PHQ-8 is a truncated version of the Patient Health Questionnaire-9, which consists of 9 domains that correspond to the Diagnostic and Statistical Manual of Mental Disorder diagnostic criteria for major depression. Patients describe the frequency of psychological symptoms on each domain over a 2-week recall period with 0 representing no symptoms and 3 representing daily symptoms. Scores range from 0 to 24, and prior studies have demonstrated that a score ≥10 corresponds to significant clinical depression (20).
The EQ-5D is a health status measure that assesses 5 dimensions of general health (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), using a 3-level scale. These scores can then be converted to utilities using an algorithm developed for the U.S. population (21). Utilities are preference-weighted health status assessments with scores that range from 0 to 1, with 1 representing perfect health and 0 representing poorest health (22).
The QoL substudy was limited to the first 1,800 patients enrolled in the EXCEL trial. The analytic population included all randomized patients with available baseline health status data and was analyzed on an intention to treat basis. Baseline characteristics were compared between groups using Student’s t-tests for continuous variables and chi-square tests for categorical variables. Clinical event rates through 3 years of follow-up were based on Kaplan-Meier estimates and compared between groups using the log-rank test. Within-group comparisons were performed using paired Student’s t-tests to evaluate changes in health status between baseline and 1 month, 12 months, and 36 months. Differences in health status between CABG and PCI at each time point were estimated using longitudinal random-effect growth curve models for all scales. By incorporating all available health status data at all time points, including those for patients who died, withdrew from the study, or were lost to follow-up, these models account for missing data under the missing-at-random assumption. Covariates for the growth curve models included baseline score for the health status measure being assessed, treatment group, follow-up time, and interactions between treatment and follow-up time. The intercept and linear time effects were estimated using both fixed and random effects, whereas quadratic and cubic effects of time were modeled as fixed effects only to avoid overparameterization. These models were optimized using backward elimination, starting with the highest order time-by-treatment interaction, using a p value of <0.05 for variable retention.
In addition to treating health status measures as continuous variables, we performed secondary analyses in which certain scales were treated as categorical variables. For the SAQ–Angina Frequency Scale (SAQ-AF), patients were categorized as being angina-free (SAQ-AF score of 100) or as having monthly (SAQ-AF score 70 to 90) or daily/weekly (SAQ-AF score ≤60) angina. For the PHQ-8, patients were categorized as having clinically significant depression if they had a PHQ-8 score ≥10 (20). Analyses of these categorical endpoints were performed using logistic regression (for binary outcomes) or ordinal logistic regression (for multilevel outcomes).
Finally, exploratory analyses were performed to assess the effect of PCI versus CABG on the SAQ-AF scale at 12 and 36 months for the following subgroups: age (<65 vs. 65 to 75 vs. >75 years); sex; diabetic status; SYNTAX score (≤22 vs. 23 to 32 vs. ≥33 as determined by the angiographic core laboratory); type of LM disease (involving bifurcation/trifurcation vs. not); and baseline angina frequency (none vs. daily/weekly vs. monthly). These analyses were performed by addition of a treatment-by-subgroup interaction term to the growth curve models at both the 12- and 36-month time points.
All tests of statistical significance were 2-tailed. A p value of <0.05 was considered significant for all primary and secondary analyses. Given the large number of comparisons, a p value of <0.01 was considered significant for subgroup analyses. All analyses were performed using SAS for Windows software version 9.4 (SAS Institute, Cary, North Carolina).
Patient population and clinical outcomes
Between September 2010 and March 2014, 1,905 patients with LMCAD were randomized to revascularization with PCI (n = 948) or CABG (n = 957). Baseline health status data were available for 1,788 patients (892 PCI; 896 CABG), which constituted the analytic cohort for this study (Online Figure 1). Overall, the groups were similar in terms of baseline characteristics, although the core laboratory–defined SYNTAX score was slightly higher in the PCI group than in the CABG group (Table 1). There were no significant differences in baseline health status measures between the 2 groups. Approximately 40% of patients had daily or weekly angina, and 47% reported at least moderate dyspnea (RDS ≥2). Generic health status scales also demonstrated meaningful limitations with a mean SF-12 physical component score of ∼38 (∼1 SD below the national mean), and 21% of patients reported clinically significant depression (PHQ-8 score ≥10).
Clinical outcomes for all randomized patients through a full 36 months of follow-up are summarized in Online Table 1. At 36 months, there were no significant differences in rates of cardiovascular mortality, all-cause mortality, MI, or stroke between the 2 cohorts although the rate of ischemia-driven revascularization was higher in the PCI group than in the CABG group (12.6% vs. 7.2%, p < 0.01). Outcomes were virtually identical for the QoL analytic cohort (Online Table 2).
Antianginal and other cardiac medication use
The use of cardiac medications at each follow-up time point is summarized in Online Table 3. Beta-blockers were used more frequently after CABG than PCI at all time points. Both calcium-channel blockers and long-acting nitrates were used in <25% of patients without significant differences between treatment groups at any time point.
Within group comparisons
Compliance with the health status assessments is summarized in Online Table 4. SAQ data were available for ≥80% of patients at all follow-up time points with no significant differences between treatment groups. Baseline clinical characteristics were not significantly different between surviving patients with and without available 36-month health status data (Online Table 5).
Changes in health status at each follow-up time point are summarized in Table 2. By 1 month, the mean SAQ-AF score had increased by >20 points in both groups (p < 0.01 compared with baseline). In the PCI group, both disease-specific and generic health status measures improved significantly by 1 month, and these improvements were largely sustained at 12 and 36 months. In contrast, patients assigned to CABG demonstrated only small improvements or even declines in health status on several scales (especially measures of physical limitation) at 1 month. However, by 12 and 36 months, health status had improved significantly across all scales in the CABG group.
Differences in disease-specific health status between treatment groups are summarized in the Central Illustration and Online Table 6. At 1 month, patients treated with PCI had higher scores on each of the SAQ subscales compared with CABG, with differences ranging from 1.5 points (95% confidence interval [CI]: 0.2 to 2.9; p = 0.03) on the SAQ-AF scale to 16.1 points (95% CI: 13.9 to 18.4; p < 0.01) on the SAQ–physical limitations scale. By 12 and 36 months, there were no significant differences between the PCI and CABG groups on any of the SAQ subscales. Similar results were seen when the SAQ-AF scale was analyzed as an ordinal variable. At 1 month, the rate of daily or weekly angina in the CABG group was nearly twice the rate observed in the PCI group (10.4% vs. 5.5%; odds ratio [OR]: 2.3; 95% CI: 1.8 to 3.0; p < 0.01); however, this difference was no longer apparent at later time points (Figure 1).
In addition to changes in angina symptoms, LMCAD revascularization with either PCI or CABG was associated with significant reductions in dyspnea as assessed by the RDS (Figure 2). Similar to the findings on the SAQ, the rate of improvement in dyspnea was more rapid with PCI. At 1 month, 59.9% of patients in the PCI group were dyspnea-free as compared with 43.7% in the CABG group (p < 0.01); however, there were no significant differences in dyspnea between the groups at 12 and 36 months.
Between-group differences in generic health status measures over time are summarized in Figure 3 and Online Table 6. As with the disease-specific health status measures, randomization to PCI led to more rapid improvement in overall physical and mental health compared with CABG. At 1 month, PCI was associated with significantly better scores on both the SF-12 physical component summary scale (mean adjusted mean difference: 8.2 points; 95% CI: 7.3 to 9.1; p < 0.01) and the SF-12 mental component summary scale (adjusted mean difference: 2.0 points; 95% CI: 1.1 to 2.9; p < 0.01). Depressive symptoms, as measured by the PHQ-8, were less frequent with PCI both at 1 month (adjusted mean difference: −2.3 points; 95% CI: −2.7 to −1.9; p < 0.01) and at 12 months (adjusted mean difference: −0.4 points; 95% CI: −0.8 to 0.0; p = 0.04) but not at 36 months (adjusted mean difference: −0.4 points; 95% CI: −0.7 to 0.2; p = 0.23). Similarly, when the PHQ-8 was analyzed as a categorical variable, the rate of significant clinical depression (defined as PHQ-8 ≥10) was lower among PCI patients than CABG patients at both 1 month (7.7% vs. 19.0%; OR: 3.7; 95% CI: 2.5 to 5.4; p < 0.01) and 12 months (8.4% vs. 11.8%; OR: 1.8; 95% CI: 1.2 to 2.7; p = 0.03); however, no significant difference was seen at 36 months (8.6% vs. 8.1%; OR: 1.0; 95% CI: 0.6 to 1.6; p = 0.77). There were no significant QoL differences between CABG and PCI on any generic health status scales at 36 months.
The effect of PCI versus CABG on the SAQ-AF within pre-specified subgroups at 12 and 36 months is summarized in Online Figures 2 and 3. At both 12- and 36-month follow-ups, there was no evidence of differential treatment benefit according to age, sex, diabetic status, LM lesion location, or baseline angina frequency. At 36 months (but not at 12 months), there was a trend toward greater angina relief with CABG among patients with a low baseline SYNTAX score as compared with intermediate and high SYNTAX scores (mean treatment effect of PCI vs. CABG: −3.3, 0.8, and −0.2 points, respectively; p value for interaction = 0.03). However, given the large number of subgroup comparisons performed, this finding did not achieve the pre-specified level of statistical significance.
As data on long-term safety and effectiveness of DES have accumulated, PCI has been increasingly accepted as a reasonable revascularization strategy for patients with LMCAD. As such, choosing between PCI and CABG for LMCAD patients with low or intermediate CAD complexity requires considering other factors. This is the first study to compare the effects of PCI with a contemporary DES with those of CABG on patient-reported outcomes specifically in LMCAD patients. In this large, multicenter, randomized trial, we found that both PCI and CABG were associated with clinically meaningful and statistically significant improvements in disease-specific and generic health status that were sustained through 36 months. Not surprisingly, PCI resulted in significantly better health status compared with CABG at 1 month (particularly for those domains related to physical function and dyspnea). Nonetheless, there were no significant differences in QoL between the groups at 36 months, and these results were consistent across multiple subgroups.
Over the past 2 decades, several studies have compared health status outcomes after PCI versus CABG for the treatment of multivessel CAD and LMCAD. These studies have used a variety of PCI techniques including balloon angioplasty (23–25), bare-metal stents (26,27), and first-generation DES (7,8,28). In general, these trials have demonstrated an early QoL benefit with PCI (reflecting the less invasive nature of PCI) followed by superior angina relief with CABG in the long run (7,8,24,28). As percutaneous devices have evolved, the magnitude of long-term health status benefit provided by CABG as compared with PCI has decreased. Nonetheless, even recent trials that have compared health status outcomes after PCI using DES versus CABG (e.g., FREEDOM [Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease] and SYNTAX) have found that CABG resulted in slightly better long-term angina relief than PCI (7,8), although it is important to note that these studies were performed with first-generation DES.
In contrast to previous trials, in the EXCEL trial (in which a second-generation DES was used), there were no differences in long-term health status outcomes observed between PCI and CABG. There are several potential explanations for this finding. First, although the rate of repeat revascularization was higher with PCI than with CABG in EXCEL, the absolute difference in repeat revascularization rates was substantially lower than in previous trials (29,30). Because repeat revascularization has been associated with worse health-related QoL after CABG than PCI has (31), a modest excess of repeat revascularization with PCI (as seen in EXCEL) might not result in long-term health status impairment compared with CABG. It is also possible that the difference in outcomes relates to specific characteristics of the coronary anatomy of the EXCEL population. Indeed, the EXCEL trial included only patients with LMCAD and attempted to exclude patients with anatomically complex disease (although ∼25% of patients did have a SYNTAX score of ≥33 as determined by the angiographic core laboratory). Of note, previous studies have demonstrated that the long-term antianginal benefit of CABG compared with PCI is most pronounced in those patients with anatomically complex disease (7,8). Finally, the disparity in follow-up time points for health status assessment (i.e., 3 years in EXCEL vs. 5 years in FREEDOM and SYNTAX) could account for the inconsistent findings because the advantage of CABG in patient-reported outcomes was primarily seen at 5 years in the earlier trials.
It is also noteworthy that we found no meaningful subgroup differences in the effect of revascularization strategy on health status in EXCEL. As noted, prior studies from the DES era have demonstrated that the antianginal benefits of CABG compared with PCI are accentuated in patients with high SYNTAX scores (7,8) as well as in patients with more severe angina at baseline (7). Conversely, in EXCEL, there were no significant interactions between the extent of angina relief provided by PCI versus CABG and either SYNTAX score or baseline angina frequency. It is unclear whether these divergent findings on subgroup analyses are related to differences in patient population, trial design (e.g., stent type, follow-up duration), or to the evolution of PCI techniques over time.
Finally, the EXCEL QoL study differs from previous studies by inclusion of a specific health status measure to assess for depression. Whereas prior studies have assessed mental health through generic health status scales such as the SF-36 or SF-12, the EXCEL trial incorporated the PHQ-8, which is a more sensitive and specific instrument for depression. Prior studies have demonstrated rates of new-onset depression of ∼20% after CABG (32) and have proposed multiple possible mechanisms, including a heightened inflammatory response (33) or altered platelet reactivity after cardiopulmonary bypass (34) to account for this observation. As such, we hypothesized that PCI might produce less depression than CABG in the long run. Indeed, in the EXCEL trial, we observed lower rates of depressive symptoms with PCI as compared with CABG, not only at 1 month follow-up, but also at 1 year. Because depression has been associated with up to a 2-fold higher rate of cardiac events after CABG (32,35), it will be important to confirm this finding with further studies as the presence of depression might influence the choice of revascularization strategy in the future for LMCAD patients who are anatomically suitable for either PCI or CABG.
First, our findings apply specifically to patients with LMCAD with low and medium anatomic complexity who are suitable for both PCI and CABG. Hence, these findings cannot be extended to patients who are inoperable or to patients who have coronary anatomy that renders them unsuitable for treatment with PCI. Second, QoL data were missing in ∼20% of patients in both treatment groups at 3 years of follow-up. To account for missing data, our between-group comparisons were based on growth curve models, which use all available data under the missing-at-random assumption. Although it is not possible to prove whether data were truly missing at random, it is reassuring that rates of missing data were similar in both treatment groups and there were no significant differences in baseline characteristics between those patients who had available 3-year health status data versus those patients who did not. Finally, QoL data were only available through 36 months. As such, whether these findings are durable beyond this time frame is unknown. Although 5-year QoL follow-up had originally been planned in EXCEL, budget constraints necessitated the elimination of 5-year QoL data collection. However, it should be noted that none of the trial results were available at the time this protocol amendment was made.
Among patients with LMCAD with low or intermediate CAD complexity, PCI using a second-generation everolimus-eluting stent and CABG result in substantial and similar QoL improvement through 36 months, although a greater early benefit was observed with PCI. Taken together with the 3-year clinical data from EXCEL, these results suggest that PCI and CABG provide comparable intermediate-term outcomes for appropriately selected patients with LMCAD.
COMPETENCY IN MEDICAL KNOWLEDGE: In patients with LMCAD and low or intermediate disease complexity, PCI resulted in more rapid recovery and better early health status benefit than CABG surgery, and in those with complex CAD, despite higher rates of repeat revascularization, there was no significant difference between the 2 treatment groups in health status at 3 years.
TRANSLATIONAL OUTLOOK: Longer-term studies are needed to further evaluate the durability of health status benefits achieved with PCI compared to CABG beyond 3 years.
The EXCEL clinical trial and quality of life substudy was funded by a research grant from Abbott Vascular. Dr. Baron has consulted for Edwards Lifesciences and St. Jude Medical Inc.; and has received travel reimbursement from Medtronic. Dr. Magnuson has received research grant support from Abbott Vascular, AstraZeneca, Boston Scientific, Daiichi-Sankyo, Edwards Lifesciences, Eli Lilly, and Medtronic; and consulted for Daiichi-Sankyo. Dr. Kandzari has received institutional research/grant support from Abbott Vascular, St. Jude Medical, Biotronik, Boston Scientific, Medinol, and Medtronic; and has consulted for Biotronik, Boston Scientific, Medtronic, and Micell Technologies. Dr. Puskas has received royalties from Scanlan Inc. Dr. Lembo has served on the advisory board of Abbott Vascular; and has served on the speakers bureaus of Abbott Vascular, Boston Scientific, and Medtronic. Dr. Banning has received an institutional educational grant from Boston Scientific; and has served on the speakers bureaus of Medtronic, Abbott Vascular, Boston Scientific, and Philips. Dr. Simonton is an employee of Abbott Vascular. Dr. Kappetein is an employee of Medtronic. Dr. Serruys has consulted for Abbott Vascular, AstraZeneca Pharmaceuticals, Biotronik, Cardialysis B.V., GLG Research, Medtronic, Sinu Medical Sciences Technology Inc., Societe Europa Digital and Publishing, Stentys France, Svelte Medical Systems Inc., Volcano/Philips Europe, Q3 Medical Devices Limited, and St. Jude Medical; and is a change advisory board member of Xeltis. Dr. Stone has consulted for Reva Medical; and has received royalty payments from Abbott Vascular to his employer, Columbia University, for sale of MitraClip. Dr. Cohen has received research grant support from Abbott Vascular, Edwards Lifesciences, Medtronic, and Boston Scientific; and has consulted for Edwards Lifesciences and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- coronary artery bypass graft surgery
- confidence interval(s)
- drug-eluting stent(s)
- left main coronary artery disease
- myocardial infarction
- odd ratio(s)
- percutaneous coronary intervention
- Patient Health Questionnaire-8
- quality of life
- Rose Dyspnea Scale
- Seattle Angina Questionnaire
- Seattle Angina Questionnaire–Angina Frequency Scale
- 12-Item Short Form Health Survey
- Received September 15, 2017.
- Revision received October 5, 2017.
- Accepted October 17, 2017.
- 2017 American College of Cardiology Foundation
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