Does percutaneous coronary intervention with everolimus-eluting stent reduce long-term all-cause death compared to coronary artery bypass graft surgery in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction?
PCI with everolimus-eluting stents provides comparable long-term survival to CABG in patients with multivessel disease and severe LV dysfunction, challenging current guidelines that favor CABG.
Background— Guidelines recommend coronary artery bypass graft surgery (CABG) over percutaneous coronary intervention (PCI) for multivessel disease and severe left ventricular systolic dysfunction. However, CABG has not been compared with PCI in such patients in randomized trials. Methods and Results— Patients with multivessel disease and severe left ventricular systolic dysfunction (ejection fraction ≤35%) who underwent either PCI with everolimus-eluting stent or CABG were selected from the New York State registries. The primary outcome was long-term all-cause death. Secondary outcomes were individual outcomes of myocardial infarction, stroke, and repeat revascularization. Among the 4616 patients who fulfilled our inclusion criteria (1351 everolimus-eluting stent and 3265 CABG), propensity score matching identified 2126 patients with similar propensity scores. In the short term, PCI was associated with a lower risk of stroke (hazard ratio HR, 0.05; 95% confidence interval CI, 0.01–0.39; P =0.004) in comparison with CABG. At long-term follow-up (median, 2.9 years), PCI was associated with a similar risk of death (HR, 1.01; 95% CI, 0.81–1.28; P =0.91), a higher risk of myocardial infarction (HR, 2.16; 95% CI, 1.42–3.28; P =0.0003), a lower risk of stroke (HR, 0.57; 95% CI, 0.33–0.97; P =0.04), and a higher risk of repeat revascularization (HR, 2.54; 95% CI, 1.88–3.44; P <0.0001). The test for interaction was significant ( P =0.002) for completeness of revascularization, such that, in patients in whom complete revascularization was achieved with PCI, there was no difference in myocardial infarction between PCI and CABG. Conclusions— Among patients with multivessel disease and severe left ventricular systolic dysfunction, PCI with everolimus-eluting stent had comparable long-term survival in comparison with CABG. PCI was associated with higher risk of myocardial infarction (in those with incomplete revascularization) and repeat revascularization, and CABG was associated with higher risk of stroke.
Bangalore et al. (Fri,) studied this question.