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Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final five-year follow-up of the SYNTAX trial.
Eur Heart J 2014; 35(40):2821-30EH

Abstract

AIMS

Coronary artery bypass grafting (CABG) has been considered the standard of care for patients with three-vessel disease (3VD), but long-term comparative results from randomized trials of CABG vs. percutaneous coronary intervention (PCI) using drug-eluting stents (DES) remain limited.

METHODS AND RESULTS

Patients with de novo 3VD or left main disease were randomly assigned to PCI with the paclitaxel-eluting first-generation stent or CABG in the SYNTAX trial. This pre-specified analysis presents the 5-year outcomes of patients with 3VD (n = 1095). The rate of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in patients with PCI compared with CABG (37.5 vs. 24.2%, respectively; P < 0.001). Percutaneous coronary intervention as opposed to CABG resulted in significantly higher rates of the composite of death/stroke/myocardial infarction (MI) (22.0 vs. 14.0%, respectively; P < 0.001), all-cause death (14.6 vs. 9.2%, respectively; P = 0.006), MI (9.2 vs. 4.0%, respectively; P = 0.001), and repeat revascularization (25.4 vs. 12.6%, respectively; P < 0.001); however, stroke was similar between groups at 5 years (3.0 vs. 3.5%, respectively; P = 0.66). Results were dependent on lesion complexity (P for interaction = 0.12); in patients with a low (0-22) SYNTAX score, PCI vs. CABG resulted in similar rates of MACCE (33.3% vs. 26.8%, respectively; P = 0.21) but significantly more repeat revascularization (25.4% vs. 12.6%, respectively; P = 0.038), while in intermediate (23-32) or high (≥ 33) SYNTAX score terciles, CABG demonstrated clear superiority in terms of MACCE, death, MI, and repeat revascularization. Differences in MACCE between PCI and CABG were larger in diabetics [hazard ratio (HR) = 2.30] than non-diabetics (HR = 1.51), although the P for interaction failed to reach significance for MACCE (P for interaction = 0.095) or any of the other endpoints.

CONCLUSION

Five-year results of patients with 3VD treated with CABG or PCI using the first-generation paclitaxel-eluting DES suggest that CABG should remain the standard of care as it resulted in significantly lower rates of death, MI, and repeat revascularization, while stroke rates were similar. For patients with low SYNTAX scores, PCI is an acceptable revascularization strategy, although at a price of significantly higher rates of repeat revascularization.

CLINICAL TRIAL REGISTRATION

NCT00114972.

Authors+Show Affiliations

Erasmus University Medical Center, Rotterdam, The Netherlands.Herzzentrum Universität Leipzig, Strumpelstrasse 39, Leipzig 4289, Germany.Erasmus University Medical Center, Rotterdam, The Netherlands.Guy's and St. Thomas' Hospital, London, UK.San Raffaele Scientific Institute, Milan, Italy.Medical City Hospital, Dallas, TX, USA.Institut Hospitalier Jacques Cartier, Générale de santé, Massy, France.May Clinic Rochester, Rochester, MN, USA.Evanston Hospital, Evanston, IL, USA.University Hospital Uppsala, Uppsala, Sweden.Boston Scientific Corporation, Natick, MA, USA.Boston Scientific Corporation, Natick, MA, USA.Erasmus University Medical Center, Rotterdam, The Netherlands.Herzzentrum Universität Leipzig, Strumpelstrasse 39, Leipzig 4289, Germany mohrf@medizin.uni-leipzig.de.

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

24849105

Citation

Head, Stuart J., et al. "Coronary Artery Bypass Grafting Vs. Percutaneous Coronary Intervention for Patients With Three-vessel Disease: Final Five-year Follow-up of the SYNTAX Trial." European Heart Journal, vol. 35, no. 40, 2014, pp. 2821-30.
Head SJ, Davierwala PM, Serruys PW, et al. Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final five-year follow-up of the SYNTAX trial. Eur Heart J. 2014;35(40):2821-30.
Head, S. J., Davierwala, P. M., Serruys, P. W., Redwood, S. R., Colombo, A., Mack, M. J., ... Mohr, F. W. (2014). Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final five-year follow-up of the SYNTAX trial. European Heart Journal, 35(40), pp. 2821-30. doi:10.1093/eurheartj/ehu213.
Head SJ, et al. Coronary Artery Bypass Grafting Vs. Percutaneous Coronary Intervention for Patients With Three-vessel Disease: Final Five-year Follow-up of the SYNTAX Trial. Eur Heart J. 2014 Oct 21;35(40):2821-30. PubMed PMID: 24849105.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final five-year follow-up of the SYNTAX trial. AU - Head,Stuart J, AU - Davierwala,Piroze M, AU - Serruys,Patrick W, AU - Redwood,Simon R, AU - Colombo,Antonio, AU - Mack,Michael J, AU - Morice,Marie-Claude, AU - Holmes,David R,Jr AU - Feldman,Ted E, AU - Ståhle,Elisabeth, AU - Underwood,Paul, AU - Dawkins,Keith D, AU - Kappetein,A Pieter, AU - Mohr,Friedrich W, Y1 - 2014/05/21/ PY - 2014/5/23/entrez PY - 2014/5/23/pubmed PY - 2015/6/18/medline KW - Coronary artery bypass grafting KW - Diabetes KW - Incomplete revascularization KW - Percutaneous coronary intervention KW - Randomized trial KW - SYNTAX KW - Three-vessel disease SP - 2821 EP - 30 JF - European heart journal JO - Eur. Heart J. VL - 35 IS - 40 N2 - AIMS: Coronary artery bypass grafting (CABG) has been considered the standard of care for patients with three-vessel disease (3VD), but long-term comparative results from randomized trials of CABG vs. percutaneous coronary intervention (PCI) using drug-eluting stents (DES) remain limited. METHODS AND RESULTS: Patients with de novo 3VD or left main disease were randomly assigned to PCI with the paclitaxel-eluting first-generation stent or CABG in the SYNTAX trial. This pre-specified analysis presents the 5-year outcomes of patients with 3VD (n = 1095). The rate of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in patients with PCI compared with CABG (37.5 vs. 24.2%, respectively; P < 0.001). Percutaneous coronary intervention as opposed to CABG resulted in significantly higher rates of the composite of death/stroke/myocardial infarction (MI) (22.0 vs. 14.0%, respectively; P < 0.001), all-cause death (14.6 vs. 9.2%, respectively; P = 0.006), MI (9.2 vs. 4.0%, respectively; P = 0.001), and repeat revascularization (25.4 vs. 12.6%, respectively; P < 0.001); however, stroke was similar between groups at 5 years (3.0 vs. 3.5%, respectively; P = 0.66). Results were dependent on lesion complexity (P for interaction = 0.12); in patients with a low (0-22) SYNTAX score, PCI vs. CABG resulted in similar rates of MACCE (33.3% vs. 26.8%, respectively; P = 0.21) but significantly more repeat revascularization (25.4% vs. 12.6%, respectively; P = 0.038), while in intermediate (23-32) or high (≥ 33) SYNTAX score terciles, CABG demonstrated clear superiority in terms of MACCE, death, MI, and repeat revascularization. Differences in MACCE between PCI and CABG were larger in diabetics [hazard ratio (HR) = 2.30] than non-diabetics (HR = 1.51), although the P for interaction failed to reach significance for MACCE (P for interaction = 0.095) or any of the other endpoints. CONCLUSION: Five-year results of patients with 3VD treated with CABG or PCI using the first-generation paclitaxel-eluting DES suggest that CABG should remain the standard of care as it resulted in significantly lower rates of death, MI, and repeat revascularization, while stroke rates were similar. For patients with low SYNTAX scores, PCI is an acceptable revascularization strategy, although at a price of significantly higher rates of repeat revascularization. CLINICAL TRIAL REGISTRATION: NCT00114972. SN - 1522-9645 UR - https://www.unboundmedicine.com/medline/citation/24849105/Coronary_artery_bypass_grafting_vs__percutaneous_coronary_intervention_for_patients_with_three_vessel_disease:_final_five_year_follow_up_of_the_SYNTAX_trial_ L2 - https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehu213 DB - PRIME DP - Unbound Medicine ER -