CABG outshines PCI for long-term risk reduction

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 - Neon Heart

CABG offers a greater long-term benefit to patients with multivessel disease than PCI does, regardless of diabetes status, according to a meta-analysis published online Dec. 2 in JAMA Internal Medicine. CABG reduced the risk of death or MI but showed a trend toward excess strokes.

Clinical trials comparing the two treatments have lacked sufficient power to detect all-cause mortality and differences in MI, wrote Ilke Sipahi, MD, of Acibadem University Medical School in Istanbul, Turkey, and colleagues. They conducted a meta-analysis of CABG vs. PCI clinical trials in an effort to overcome that limitation.

They searched MEDLINE through December 2012 for clinical trials that randomized patients with multivessel disease to either CABG or PCI and included mortality and outcomes data beyond one-year follow-up. The trials had to reflect current clinical practice to be included.

They identified six trials, two of which enrolled patients with diabetes, with 3,023 patients in CABG arms and 3,032 in PCI arms. The weighted average follow-up was 4.1 years.

The meta-analysis showed a significant reduction in the risk of total mortality with CABG, at 27 percent, and a significant reduction in the risk of MI, at 42 percent, compared with PCI. CABG also compared favorably for repeat revascularization and major adverse cardiac and cerebrovascular events but it had a nonsignificant increased risk for stroke.

Sipahi et al wrote that the long-term reduced risk of death and MI with CABG remained, whether PCI involved drug-eluting stents or bare-metal stents. The mortality risk reduction with CABG also was similar for patients with or without diabetes, at 25 percent and 28 percent, respectively.

“Our results strongly suggest that CABG should be the revascularization method in patients with multivessel CAD [coronary artery disease], regardless of their diabetic status,” they wrote. “However, it should be remembered that the included trials enrolled patients mostly with stable or unstable angina and excluded patients with acute MI. Therefore, our findings do not apply to the type of patients who were systematically excluded from these trials.”

They added that they could not perform subgroup analyses because they lacked individual patient-level data. One trial included patients randomized to medical management, PCI or CABG, and while they argued that CABG may be superior to medical management, too, no sufficiently powered trial has been conducted to demonstrate that.