Article

Systematic review: The comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery

Center for Primary Care and Outcomes Research and Stanford University School of Medicine, Stanford, California 94305-6019, USA.
Annals of internal medicine (Impact Factor: 16.1). 11/2007; 147(10):703-16.
Source: PubMed

ABSTRACT The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood.
To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated.
MEDLINE, EMBASE, and Cochrane databases (1966-2006); conference proceedings; and bibliographies of retrieved articles.
Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.
Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.
The authors identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedure-related strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG-PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.
The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.
Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures.

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    • "Several randomized controlled trials (RCTs) and meta-analyses comparing percutaneous coronary interventions (PCIs) with coronary artery bypass grafting (CABG) demonstrated similar longterm survival outcomes for PCI and CABG [1] [2] [3] [4]. However, these studies may not accurately reflect current clinical practice of coronary revascularization for following reasons. "
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    ABSTRACT: Although there have been several studies that compared the efficacy of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), the impact of off-pump CABG (OPCAB) has not been well elucidated. The objective of the present study was to compare the outcomes after PCI, on-pump CABG (ONCAB), and OPCAB in patients with multivessel and/or left main disease. Among the 9877 patients undergoing first PCI using bare-metal stents or CABG who were enrolled in the CREDO-Kyoto Registry, 6327 patients with multivessel and/or left main disease were enrolled into the present study (67.9±9.8 years old). Among them, 3877 patients received PCI, 1388 ONCAB, and 1069 OPCAB. Median follow-up was 3.5 years. Comparing PCI with all CABG (ONCAB and OPCAB), propensity-score-adjusted all-cause mortality after PCI was higher than that CABG (hazard ratio (95% confidence interval): 1.37 (1.15-1.63), p<0.01). The incidence of stroke was lower after PCI than that after CABG (0.75 (0.59-0.96), p=0.02). CABG was associated with better survival outcomes than PCI in the elderly (interaction p=0.04). Comparing OPCAB with PCI or ONCAB, propensity-score-adjusted all-cause mortality after PCI was higher than that after OPCAB (1.50 (1.20-1.86), p<0.01). Adjusted mortality was similar between ONCAB and OPCAB (1.18 (0.93-1.51), p=0.33). The incidence of stroke after OPCAB was similar to that after PCI (0.98 (0.71-1.34), p>0.99), but incidence of stroke after ONCAB was higher than that after OPCAB (1.59 (1.16-2.18), p<0.01). In patients with multivessel and/or left main disease, CABG, particularly OPCAB, is associated with better survival outcomes than PCI using bare-metal stents. Survival outcomes are similar between ONCAB and OPCAB.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 06/2011; 41(1):94-101. DOI:10.1016/j.ejcts.2011.04.004 · 2.81 Impact Factor
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    • "It has been shown that there are comparable overall safety outcomes (death, acute myocardium infarction, cerebrovascular accident) in CABG and PCI patients, but repeat revascularization procedures remain higher after PCI [1] [2]. "
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    ABSTRACT: Coronary artery bypass grafting (CABG) has been shown to provide better results than percutaneous coronary intervention (PCI) in multivessel coronary disease. Drug-eluting stents (DES) have significantly improved results of PCI in terms of restenosis but the advantages of such a treatment compared to CABG remain uncertain. This meta-analysis summarizes available data from observational cohorts comparing DES-PCI versus CABG. We performed a systematic literature search for observational cohorts comparing CABG versus DES-PCI in patients with multivessel coronary disease. The mixed model method was used to obtain the pooled hazard ratio (HR) for outcomes of interest. A total of nine observational nonrandomized studies were identified and analyzed including a total of 24,268 patients with multivessel coronary disease who underwent DES-PCI (n=13,540) and CABG (n=10,728). Mean follow-up time was 20 months. Pooled analysis showed that DES-PCI and CABG were comparable in terms of composite occurrence of death, acute myocardial infarction and cerebrovascular accidents (HR=0.94; 95% CI=0.72-1.22; p=0.66). However, there was a significantly higher risk of repeat revascularization in the DES-PCI group (HR=4.06; 95% CI=2.64-6.24; p<0.001). Overall major adverse cardiac and cerebrovascular events rate in the DES-PCI was higher compared to the CABG group (HR=1.86; 95% CI=1.36-2.54; p<0.001). In the 'real world' clinical practice, overall major adverse cardiac and cerebrovascular events rate continues to be higher after DES-PCI due to an excess of redo revascularization compared with CABG.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 04/2009; 36(4):611-5. DOI:10.1016/j.ejcts.2009.03.012 · 2.81 Impact Factor
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    ABSTRACT: The SYNTAX study randomized patients (pts) with three-vessel or left main coronary artery disease (CAD) into pts who underwent bypass grafting (CABG) or percutaneous coronary intervention (PCI). The primary endpoint of the study was a major adverse cardiac or cerebrovascular event (death from any cause, stroke, myocardial infarction, repeated revascularization)(MACCE). Rates of MACCE at 12months were significantly higher in the PCI group (17.8%) than in the CAGB group (12.4%, p < 0.002). This was caused by an increased rate of repeated revascularizations in PCI pts (13.5%) compared to CABG pts (5.9%, p < 0.001). The rates of death and myocardial infarction were similar between the two groups. Stroke was significantly more likely to occur with CABG (2.2%) versus 0.6% with PCI (p = 0.003). Despite the results of the SYNTAX study, an individual strategy is necessary for each patient. KeywordsCABG–PCI–Major adverse events–Revascularization–Death–Stroke
    Clinical Research in Cardiology Supplements 04/2010; 5:70-74. DOI:10.1007/s11789-010-0004-0
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