CABG vs PCI for severe coronary artery disease
Coronary artery bypass graft (CABG) is still the treatment of choice for patients with triple vessel or left main coronary artery disease, the results of a large study suggest.
The SYNTAX trial was a multicentre, prospective, randomised, controlled trial comparing outcomes in patients with severe coronary disease treated with either percutaneous coronary intervention (PCI) or CABG. Each group utilised contemporary techniques, with drug- eluting stents and optimal antiplatelet regimens in the PCI group and arterial grafts in the CABG group.
A total of 1,800 patients were enrolled with triple vessel or left main stem coronary disease and randomised to either PCI or CABG. Importantly, all the patients were deemed to be candidates for adequate revascularisation regardless of the method chosen. The primary endpoint was a composite of death from any cause, major adverse cardiac or cerebrovascular events such as stroke and myocardial infarction, or repeat revascularisation during the 12-month period following the initial procedure.
The results showed an increase in the primary endpoint in the PCI group (17.8%, vs. 12.4% for CABG; P=0.002) which was driven by an increased rate of repeat revascularisation (13.5% vs. 5.9%, P<0.001). The mortality rate was similar in both groups (4.4% PCI vs. 3.5% CABG, P=0.37) but stroke was more common in the CABG group (2.2% vs. 0.6% with PCI; P=0.003). Therefore it would appear that CABG remains the treatment of choice for patients with severe coronary artery disease.
However, this study had some limitations such as the relatively short duration of follow-up, the fact that three quarters of the patients were male, and that CABG patients were less likely to be on optimal medical therapy which may have influenced the risk of stroke. In practical terms the SYNTAX score was developed by the investigators to guide cardiologists and surgeons as to the optimal revascularisation strategy dependent on the prevailing pattern of coronary disease.
Interventional cardiologists are increasingly responsible for coronary revascularisation procedures these days with CABG apparently on the decline. Furthermore interventionalists are tacking increasingly complex coronary disease and the advent of drug-eluting stent technology has reduced the repeat procedure rate in patients undergoing PCI. The less invasive approach is certainly popular with patients when faced with the alternative of major surgery.
Serruys, PW, Morice M-C, Kappetein P. et al. Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease. N Engl J Med 2009;360:961-72Reviewer
Dr Peter Savill
GPwSI Cardiology, Southampton