Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data
Selected in the Lancet by R.L.J. Osnabrugge
Stuart J Head, Milan Milojevic, Joost Daemen, Jung-Min Ahn, Eric Boersma, Evald H Christiansen, Michael J Domanski, Michael E Farkouh, Marcus Flather, Valentin Fuster, Mark A Hlatky, Niels R Holm, Whady A Hueb, Masoor Kamalesh, Young-Hak Kim, Timo Mäkikallio, Friedrich W Mohr, Grigorios Papageorgiou, Seung-Jung Park, Alfredo E Rodriguez, Joseph F Sabik 3rd, Rodney H Stables, Gregg W Stone, Patrick W Serruys, Arie Pieter Kappetein
Published Online ahead of print, 22 February 2018
LinkRead the abstract
Latest contributionsMortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analy... Effect of mechanically expanded vs self-expanding transcatheter aortic valve replacement on mortality and major adverse clinical events in high-ris... Valve-in-valve outcome: design impact of a pre-existing bioprosthesis on the hydrodynamics of an Edwards Sapien XT valve
Why this study – the rationale/objective?
The optimal revascularisation strategy in patients with coronary artery disease has been debated for a few decades. The aim of this study was to perform a systematic review and meta-analysis of randomised trials comparing CABG and PCI using stents.
How was it executed – the methodology?
In total, 11 randomised trials involving almost 12,000 patients were included. The mean follow-up was 3.8 years and there were a total of 976 deaths. This vast amount of data allowed the comparison of mortality, both in the overall cohort as well as in subgroups. The meta-analyses were performed with patient-level detail.
What is the main result?
Five-year mortality was higher with PCI versus CABG (11.2% versus 9.2%, Hazard Ratio [HR] 1.20; 1.06-1.37, p=0.038). Subgroup analyses showed that the mortality benefit was consistent in patients with multivessel disease and in patients with diabetes. There was no mortality difference in patients without diabetes or in patients with left main disease.
Critical reading and the relevance for clinical practice
This collaborative analysis of individual patient data from 11 randomised trials encompasses all the current randomised evidence of CABG versus PCI with stents. Although it is a meta-analysis, the pooled patient-level analysis reflects a high-quality summary of the currently available evidence. Despite the fact that several generations of stents were used in the different trials, these mortality results seem to be consistent for newer generation stents as well. The mean age of the patients was 64 years and these patients have a reasonable life-expectancy. Therefore, long-term results beyond the 3.8 years mean follow-up are needed to truly appreciate the benefits of both treatments.