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Comparison of Stenting Versus Bypass Surgery According to the Completeness of Revascularization in Severe Coronary Artery Disease: Patient-Level Pooled Analysis of the SYNTAX, PRECOMBAT, and BEST Trials.
JACC Cardiovasc Interv. 2017 07 24; 10(14):1415-1424.JC

Abstract

OBJECTIVES

The aim of this study was to compare long-term survival between patients with severe coronary artery disease undergoing coronary artery bypass grafting (CABG) and those undergoing percutaneous coronary intervention (PCI) achieving complete revascularization (CR) or incomplete revascularization.

BACKGROUND

The importance of CR in decision making regarding revascularization strategy in patients with severe coronary artery disease is unknown.

METHODS

Data were pooled from the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery), PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease), and BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease) trials. The primary outcome was death from any cause and was compared in an as-treated analysis.

RESULTS

The rate of CR was 61.7% (57.2% with PCI and 66.8% with CABG). During a median 4.9-year follow-up period (interquartile range: 4.5 to 5.0 years), compared with patients undergoing CABG with CR, those undergoing PCI with incomplete revascularization had a higher risk for death from any cause (adjusted hazard ratio [aHR]: 1.43; 95% confidence interval [CI]: 1.03 to 2.00; p = 0.036) and the composite of death, myocardial infarction, and stroke (aHR: 1.48; 95% CI: 1.14 to 1.92; p = 0.003). However, there was no significant difference between patients undergoing CABG with CR and those undergoing PCI with CR regarding the risk for death from any cause (aHR: 1.16; 95% CI: 0.83 to 1.63; p = 0.39) and the composite of death, myocardial infarction, and stroke (aHR: 1.14; 95% CI: 0.87 to 1.48; p = 0.35). Subgroup analysis of multivessel coronary disease, high SYNTAX score (>32), and diabetes showed consistent findings.

CONCLUSIONS

For the treatment of left main or multivessel coronary artery disease, PCI resulting in CR was associated with a similar long-term survival rate to CABG resulting in CR. Therefore, the ability to achieve CR should enter into the decision algorithm for choice of revascularization strategy.

Authors+Show Affiliations

Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan, Seoul, Korea.Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan, Seoul, Korea.Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan, Seoul, Korea. Electronic address: cheolwlee@amc.seoul.kr.Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan, Seoul, Korea.Erasmus University Medical Center, Amsterdam, the Netherlands.Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.Erasmus University Medical Center, Amsterdam, the Netherlands.Erasmus University Medical Center, Amsterdam, the Netherlands.Division of Biostatistics, Asan Medical Center, University of Ulsan, Seoul, Korea.Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan, Seoul, Korea.Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan, Seoul, Korea.Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan, Seoul, Korea.Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan, Seoul, Korea.Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan, Seoul, Korea.Erasmus University Medical Center, Amsterdam, the Netherlands; International Center for Circulatory Health, Imperial College of London, London, United Kingdom.Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan, Seoul, Korea.

Pub Type(s)

Comparative Study
Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

28728654

Citation

Ahn, Jung-Min, et al. "Comparison of Stenting Versus Bypass Surgery According to the Completeness of Revascularization in Severe Coronary Artery Disease: Patient-Level Pooled Analysis of the SYNTAX, PRECOMBAT, and BEST Trials." JACC. Cardiovascular Interventions, vol. 10, no. 14, 2017, pp. 1415-1424.
Ahn JM, Park DW, Lee CW, et al. Comparison of Stenting Versus Bypass Surgery According to the Completeness of Revascularization in Severe Coronary Artery Disease: Patient-Level Pooled Analysis of the SYNTAX, PRECOMBAT, and BEST Trials. JACC Cardiovasc Interv. 2017;10(14):1415-1424.
Ahn, J. M., Park, D. W., Lee, C. W., Chang, M., Cavalcante, R., Sotomi, Y., Onuma, Y., Tenekecioglu, E., Han, M., Lee, P. H., Kang, S. J., Lee, S. W., Kim, Y. H., Park, S. W., Serruys, P. W., & Park, S. J. (2017). Comparison of Stenting Versus Bypass Surgery According to the Completeness of Revascularization in Severe Coronary Artery Disease: Patient-Level Pooled Analysis of the SYNTAX, PRECOMBAT, and BEST Trials. JACC. Cardiovascular Interventions, 10(14), 1415-1424. https://doi.org/10.1016/j.jcin.2017.04.037
Ahn JM, et al. Comparison of Stenting Versus Bypass Surgery According to the Completeness of Revascularization in Severe Coronary Artery Disease: Patient-Level Pooled Analysis of the SYNTAX, PRECOMBAT, and BEST Trials. JACC Cardiovasc Interv. 2017 07 24;10(14):1415-1424. PubMed PMID: 28728654.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Comparison of Stenting Versus Bypass Surgery According to the Completeness of Revascularization in Severe Coronary Artery Disease: Patient-Level Pooled Analysis of the SYNTAX, PRECOMBAT, and BEST Trials. AU - Ahn,Jung-Min, AU - Park,Duk-Woo, AU - Lee,Cheol Whan, AU - Chang,Mineok, AU - Cavalcante,Rafael, AU - Sotomi,Yohei, AU - Onuma,Yoshinobu, AU - Tenekecioglu,Erhan, AU - Han,Minkyu, AU - Lee,Pil Hyung, AU - Kang,Soo-Jin, AU - Lee,Seung-Whan, AU - Kim,Young-Hak, AU - Park,Seong-Wook, AU - Serruys,Patrick W, AU - Park,Seung-Jung, PY - 2016/12/07/received PY - 2017/04/13/revised PY - 2017/04/17/accepted PY - 2017/7/22/entrez PY - 2017/7/22/pubmed PY - 2018/4/26/medline KW - bypass surgery KW - coronary artery disease KW - stenting SP - 1415 EP - 1424 JF - JACC. Cardiovascular interventions JO - JACC Cardiovasc Interv VL - 10 IS - 14 N2 - OBJECTIVES: The aim of this study was to compare long-term survival between patients with severe coronary artery disease undergoing coronary artery bypass grafting (CABG) and those undergoing percutaneous coronary intervention (PCI) achieving complete revascularization (CR) or incomplete revascularization. BACKGROUND: The importance of CR in decision making regarding revascularization strategy in patients with severe coronary artery disease is unknown. METHODS: Data were pooled from the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery), PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease), and BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease) trials. The primary outcome was death from any cause and was compared in an as-treated analysis. RESULTS: The rate of CR was 61.7% (57.2% with PCI and 66.8% with CABG). During a median 4.9-year follow-up period (interquartile range: 4.5 to 5.0 years), compared with patients undergoing CABG with CR, those undergoing PCI with incomplete revascularization had a higher risk for death from any cause (adjusted hazard ratio [aHR]: 1.43; 95% confidence interval [CI]: 1.03 to 2.00; p = 0.036) and the composite of death, myocardial infarction, and stroke (aHR: 1.48; 95% CI: 1.14 to 1.92; p = 0.003). However, there was no significant difference between patients undergoing CABG with CR and those undergoing PCI with CR regarding the risk for death from any cause (aHR: 1.16; 95% CI: 0.83 to 1.63; p = 0.39) and the composite of death, myocardial infarction, and stroke (aHR: 1.14; 95% CI: 0.87 to 1.48; p = 0.35). Subgroup analysis of multivessel coronary disease, high SYNTAX score (>32), and diabetes showed consistent findings. CONCLUSIONS: For the treatment of left main or multivessel coronary artery disease, PCI resulting in CR was associated with a similar long-term survival rate to CABG resulting in CR. Therefore, the ability to achieve CR should enter into the decision algorithm for choice of revascularization strategy. SN - 1876-7605 UR - https://www.unboundmedicine.com/medline/citation/28728654/Comparison_of_Stenting_Versus_Bypass_Surgery_According_to_the_Completeness_of_Revascularization_in_Severe_Coronary_Artery_Disease:_Patient_Level_Pooled_Analysis_of_the_SYNTAX_PRECOMBAT_and_BEST_Trials_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1936-8798(17)30968-8 DB - PRIME DP - Unbound Medicine ER -