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Long-Term Outcomes of Coronary-Artery Bypass Grafting Versus Stent Implantation
Cardiovascular Surgery
studies comparing stenting and CABG have found no significant mortality differences. Future studies will be needed to compare long-term outcomes for drug-eluting stents with those for CABG in patients with various baseline demographic and angiographic characteristics. DM
Abstracts Long-Term Outcomes of Coronary-Artery Bypass Grafting Versus Stent Implantation Hannan EL, Racz MJ, Walford G, et al. N Engl J Med 2005;352: 2174 – 83.
The Impact of the Introduction of Drug-eluting Stents on the Clinical Practice of Surgical and Percutaneous Treatment of Coronary Artery Disease
Study Question: This study used observational data from a large registry to compare short-term and long-term outcomes among patients with multivessel disease who underwent CABG or stenting in New York State hospitals. Methods: The researchers used New York’s cardiac registries to identify 37,212 patients with multivessel disease who underwent CABG and 22,102 patients with multivessel disease who underwent PCI from January 1, 1997, to December 31, 2000. They determined the rates of death and subsequent revascularization within 3 years after the procedure in various groups of patients according to the number of diseased vessels and the presence or absence of involvement of the left anterior descending (LAD) coronary artery. The rates of adverse outcomes were adjusted by means of proportional-hazards methods to account for differences in patients’ severity of illness before revascularization. Results: Risk-adjusted survival rates were significantly higher among patients who underwent CABG than among those who received a stent in all of the anatomical subgroups studied. For example, the adjusted hazard ratio (HR) for the long-term risk of death after CABG relative to stent implantation was 0.64 (95% confidence interval [CI] 0.56 – 0.74) for patients with three-vessel disease with involvement of the proximal LAD coronary artery and 0.76 (95% CI interval, 0.60 – 0.96) for patients with two-vessel disease with involvement of the nonproximal LAD coronary artery. Also, the 3-year rates of revascularization were considerably higher in the stenting group than in the CABG group (7.8% vs. 0.3% for subsequent CABG and 27.3% vs. 4.6% for subsequent PCI). Conclusions: The investigators concluded that for patients with ⱖ2 diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than is stenting. Perspective: This observational study reports that the adjusted HRs for the long-term risk of death after CABG relative to stent implantation ranged from 0.76 for patients with two-vessel disease with involvement of the nonproximal LAD artery to 0.64 for three-vessel disease with involvement of the proximal LAD artery. Also, revascularization rates were considerably higher after stenting than after CABG. A limitation of this study is that it is observational rather than randomized, and the possibility remains that observational studies may fail to identify all confounders, and propensity analyses may not account for selection bias related to unmeasured characteristics. Recent randomized
van Domburg RT, Lemos PA, Takkenberg JJM, et al. Eur Heart J 2005;26:675– 81. Study Question: Sirolimus-eluting stents, (SES) have recently been shown to reduce restenosis in selected patients. Researchers investigated the impact of SES on the clinical practice of CABG and PCI in a series of unselected consecutive patients. Methods: Between April and October 2002, a policy of SES implantation for all procedures was instituted in the reported hospital. In total, 798 patients were referred to PCI and 275 to CABG (SES group). A control group was composed of all interventions (806 PCI and 314 CABG) performed during the preceding 6 months (pre-SES). The main outcome was the occurrence of major adverse cardiac events (MACE) at 15 months. Results: In the SES era, a significant shift was noted in the PCI group toward more multivessel stenting (28% vs. 24%; p⬍0.05), more bifurcation stenting (18% vs. 7%; p⬍0.0001) and the use of more stents (1.9% vs. 1.5; p⬍0.05). In the PCI elective patients, a shift was noted toward more three-vessel disease (pre-SES: 16% vs. SES: 23%; p⫽0.02). Furthermore, there was a shift in the CABG group toward more impaired LV function (pre-SES: 34% vs. SES: 41%; p⫽0.02) and toward more three-vessel disease (pre-SES: 67% vs. SES: 75%; p⫽0.03). Overall, the cumulative MACE percentages at 1 year after coronary revascularization (PCI and CABG combined) decreased from 16.8% to 13.8% (p⫽0.03). The cumulative MACE percentages in the pure SES group and the pre-SES baremetal-stent group at 12 months were 15.6% and 19.8%, respectively (p⬍0.01). Conclusions: The research team concluded that introduction of the SES has had an impact on the treatment strategy of coronary artery disease (CAD), with PCI favored in more cases. Perspective: This study shows that in real life, patients with de novo lesions do indeed benefit from SES utilization. The study demonstrates that the significant reduction of coronary re-interventions after drug-eluting-stent implantation will certainly continue to have an impact on the invasive treatment of CAD. Increased use of these stents allows morecomplex coronary anatomy to be treated by PCI and results in lower repeat revascularization rates. DM
ACC CURRENT JOURNAL REVIEW August 2005
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studies comparing stenting and CABG have found no significant mortality differences. Future studies will be needed to compare long-term outcomes for drug-eluting stents with those for CABG in patients with various baseline demographic and angiographic characteristics. DM
Abstracts Long-Term Outcomes of Coronary-Artery Bypass Grafting Versus Stent Implantation Hannan EL, Racz MJ, Walford G, et al. N Engl J Med 2005;352: 2174 – 83.
The Impact of the Introduction of Drug-eluting Stents on the Clinical Practice of Surgical and Percutaneous Treatment of Coronary Artery Disease
Study Question: This study used observational data from a large registry to compare short-term and long-term outcomes among patients with multivessel disease who underwent CABG or stenting in New York State hospitals. Methods: The researchers used New York’s cardiac registries to identify 37,212 patients with multivessel disease who underwent CABG and 22,102 patients with multivessel disease who underwent PCI from January 1, 1997, to December 31, 2000. They determined the rates of death and subsequent revascularization within 3 years after the procedure in various groups of patients according to the number of diseased vessels and the presence or absence of involvement of the left anterior descending (LAD) coronary artery. The rates of adverse outcomes were adjusted by means of proportional-hazards methods to account for differences in patients’ severity of illness before revascularization. Results: Risk-adjusted survival rates were significantly higher among patients who underwent CABG than among those who received a stent in all of the anatomical subgroups studied. For example, the adjusted hazard ratio (HR) for the long-term risk of death after CABG relative to stent implantation was 0.64 (95% confidence interval [CI] 0.56 – 0.74) for patients with three-vessel disease with involvement of the proximal LAD coronary artery and 0.76 (95% CI interval, 0.60 – 0.96) for patients with two-vessel disease with involvement of the nonproximal LAD coronary artery. Also, the 3-year rates of revascularization were considerably higher in the stenting group than in the CABG group (7.8% vs. 0.3% for subsequent CABG and 27.3% vs. 4.6% for subsequent PCI). Conclusions: The investigators concluded that for patients with ⱖ2 diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than is stenting. Perspective: This observational study reports that the adjusted HRs for the long-term risk of death after CABG relative to stent implantation ranged from 0.76 for patients with two-vessel disease with involvement of the nonproximal LAD artery to 0.64 for three-vessel disease with involvement of the proximal LAD artery. Also, revascularization rates were considerably higher after stenting than after CABG. A limitation of this study is that it is observational rather than randomized, and the possibility remains that observational studies may fail to identify all confounders, and propensity analyses may not account for selection bias related to unmeasured characteristics. Recent randomized
van Domburg RT, Lemos PA, Takkenberg JJM, et al. Eur Heart J 2005;26:675– 81. Study Question: Sirolimus-eluting stents, (SES) have recently been shown to reduce restenosis in selected patients. Researchers investigated the impact of SES on the clinical practice of CABG and PCI in a series of unselected consecutive patients. Methods: Between April and October 2002, a policy of SES implantation for all procedures was instituted in the reported hospital. In total, 798 patients were referred to PCI and 275 to CABG (SES group). A control group was composed of all interventions (806 PCI and 314 CABG) performed during the preceding 6 months (pre-SES). The main outcome was the occurrence of major adverse cardiac events (MACE) at 15 months. Results: In the SES era, a significant shift was noted in the PCI group toward more multivessel stenting (28% vs. 24%; p⬍0.05), more bifurcation stenting (18% vs. 7%; p⬍0.0001) and the use of more stents (1.9% vs. 1.5; p⬍0.05). In the PCI elective patients, a shift was noted toward more three-vessel disease (pre-SES: 16% vs. SES: 23%; p⫽0.02). Furthermore, there was a shift in the CABG group toward more impaired LV function (pre-SES: 34% vs. SES: 41%; p⫽0.02) and toward more three-vessel disease (pre-SES: 67% vs. SES: 75%; p⫽0.03). Overall, the cumulative MACE percentages at 1 year after coronary revascularization (PCI and CABG combined) decreased from 16.8% to 13.8% (p⫽0.03). The cumulative MACE percentages in the pure SES group and the pre-SES baremetal-stent group at 12 months were 15.6% and 19.8%, respectively (p⬍0.01). Conclusions: The research team concluded that introduction of the SES has had an impact on the treatment strategy of coronary artery disease (CAD), with PCI favored in more cases. Perspective: This study shows that in real life, patients with de novo lesions do indeed benefit from SES utilization. The study demonstrates that the significant reduction of coronary re-interventions after drug-eluting-stent implantation will certainly continue to have an impact on the invasive treatment of CAD. Increased use of these stents allows morecomplex coronary anatomy to be treated by PCI and results in lower repeat revascularization rates. DM
ACC CURRENT JOURNAL REVIEW August 2005
58