Clinical question Is percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) preferred in patients with three-vessel or left main coronary artery disease (CAD)?
Bottom line You would have to treat 14 patients with CABG instead of PCI to prevent one revascularization, and 60 patients with PCI instead of CABG to prevent one stroke (although this is partially offset by fewer MIs in the CABG patients). Put another way, patients and physicians will have to decide whether 4 to 5 revascularizations equals one stroke. Revascularization is especially likely in patients with more complex lesions. (Level of evidence = 1b)
Synopsis Previous randomized controlled trials compared CABG with PCI using bare metal stents. Newer drug-eluting stents reduce the need for revascularization, but have not been compared with CABG in large, randomized controlled trials. In this study, patients with three-vessel or left main disease were approached for inclusion. Those patients who were thought by an interventional cardiologist and thoracic surgeon to have disease that could be treated equally well by CABG or PCI (n = 1,800) were randomized to receive PCI with drugeluting stents or CABG. The mean age of the patients was 65 years, 77% were men, 20% were smokers, and 25% had diabetes. Groups were balanced, and the analysis was by intention to treat. This was a noninferiority study, in which the null hypothesis is that there is a difference, and the study tries to prove that there isn't a difference (which is the opposite of a typical study). There were more withdrawals in the CABG group (40 vs 7), which is not explained, but crossovers and losses to follow-up were similar between groups. After the procedure, patients who underwent CABG were less likely to be taking an antiplatelet drug (24% vs 97%; P < .001), but were more likely to be taking warfarin or amiodarone. After 1 year, the “all bad things” outcome was more likely in the PCI group (17.8% vs 12.4%; P = .002; number needed to treat to harm = 18), primarily due to an increased risk of repeat vascularization (13.5% vs 5.9%; P < .001). The risk of stroke was slightly higher in the CABG group, balanced by a similar reduction in the risk of MI (although the latter was not statistically significant). All-cause mortality was 4.4% in the PCI group and 3.5% in the CABG group, a nonsignificant difference. When results were stratified by the complexity of the lesion, those with less complex lesions did just as well with either procedure, whereas those with very complex lesions had many more revascularizations with PCI.
Serruys PW, Morice MC, Kappetein AP, et al; SYNTAX Investigators. Percutaneous coronary intervention versus coronary artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961-972.