Vascular disease

No difference in PCI and CABG outcomes for left main CAD


Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have gone another round in the ring and come out seemingly tied for efficacy in left main coronary artery disease (CAD), a study presented at the American Heart Association’s Scientific Sessions 2021 suggests.

The meta-analysis of 4,394 patients across four randomised clinical trials (SYNTAX, PRECOMBAT, NOBLE and EXCEL) with at least five years’ follow-up assessed long-term outcomes in recipients of PCI with drug-eluting stents versus CABG.

It found the groups had similar risks of 5-year all-cause mortality (11.2% PCI vs 10.2% CABG, hazard ratio [HR]: 1.10, P = 0.33), with non-cardiovascular deaths making up most of the numerical difference, cardiovascular death (6.2% vs 5.9%, HR: 1.07, P = 0.61) and stroke overall (2.7% vs 3.1%, HR: 0.84, P = 0.36).

Lead author Professor Marc Sabatine of Brigham and Women’s Hospital and his team did note a small difference in 5-year all-cause mortality, based on a Bayesian analysis, but it was likely less than 0.2% per year, favouring CABG.

Additionally, while CABG patients were less likely to have spontaneous myocardial infarction or repeat revascularisation (6.2% vs 2.6%, HR: 2.35, P < 0.0001 and 18.3% vs 10.7%, HR: 1.78, P < 0.0001), PCI patients had a lower stroke risk in the first year after randomisation (HR: 0.37).

Despite their apparent similarities, the study has still failed to “clearly establish superiority or non-inferiority of PCI over the current gold standard of CABG”, due to an insufficient number of assessed patients, McMaster University cardiologists Assistant Professor Emilie Belley-Côté and Professor Philip Devereaux wrote in an accompanying editorial.

For PCI’s still unproven standing against CABG, the procedure has been championed by many interventional cardiologists for left main CAD patients with low-to-intermediate anatomical complexity, they noted, since it’s less invasive and requires a shorter recovery time.

Trials “larger than the the aggregate of SYNTAX, PRECOMBAT, NOBLE and EXCEL” are needed to cement PCI’s place in treating the condition, the commentary stated.

For now, interventional cardiologists and cardiac surgeons need to work together when choosing a revascularisation approach while considering expertise, available data and and patient preference, the authors suggested.

“Until definitive trial data become available, patients deserve to be presented with the advantages, disadvantages, and uncertainties of both approaches,” they concluded.

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