Long-term study supports CABG over PCI in young patients with severe CAD

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 - Surgery

Younger patients with three-vessel coronary artery disease benefit more from coronary artery bypass grafting (CABG) than percutaneous coronary intervention (PCI) in the long run, suggests a study presented Jan. 30 at the Society of Thoracic Surgeons’ annual meeting in Fort Lauderdale, Florida.

Senior author Wael Awad, MD, and colleagues studied 100 patients who underwent PCI and 100 who underwent CABG at London Chest Hospital in 2004. All patients were 50 or younger at the time of their operation.

The rates of myocardial infarction (MI), repeat revascularization and major adverse cardiovascular and cerebrovascular events (MACCE) were significantly higher in the PCI group at both five and 12 years of follow-up. However, the gap was driven almost entirely by patients with three-vessel disease, as there were no significant differences in MI, repeat revascularization, all-cause death, MACCE or stroke among patients with one- or two-vessel coronary artery disease (CAD).

For three-vessel disease, prevalence of three 12-year outcomes was higher for PCI than for CABG: 47.6 percent versus 19.2 percent for MI; 66.7 versus 20.5 percent for repeat revascularization; and 19 MACCE in 21 patients versus 31 in 78 patients.

“Our findings support CABG as the preferred method of revascularization in young patients with three-vessel disease,” Awad said in a press release. “PCI is reasonable and as safe as CABG in young patients, but this should be reserved for patients with single or two-vessel disease. Patients with more extensive coronary artery disease should be offered surgery.”

Said Robbin G. Cohen, MD, MMM, associate professor of cardiothoracic surgery at the University of Southern California School of Medicine, who was not involved with the study: “Despite the less invasive nature of PCI, this is yet another example where the important advantages of coronary bypass surgery make it the most effective therapy for the treatment of extensive coronary artery disease. This is especially important in younger patients whose futures rely on their long-term outcomes.”

Awad and colleagues said the long-term durability of surgery makes it a better option for younger patients with more severe CAD. But less-invasive PCI is associated with shorter hospital stays—2.4 days versus 6.6 days in their study—and may be suitable for older patients and those with less extensive CAD.

The researchers said a multidisciplinary heart team of surgeons, cardiologists and other healthcare professionals should meet to discuss the pros and cons of each procedure and relay them to patients.

“Patients, especially younger ones, are increasingly opting for less invasive procedures,” Awad said. “By providing them with all of the facts, they can make informed decisions about their treatments. It is important that patients ask questions and are fully involved in their treatment.”

Limitations of the study include that it was nonrandomized and conducted at a single-center. The baseline prevalence of diabetes (35 percent vs. 22 percent) and left ventricular ejection fraction below 50 percent (19 percent vs. 9 percent) were higher in the CABG group, as was the presence of three-vessel disease (78 patients vs. 21 patients).

Finally, because the operations were conducted in 2004 and a large proportion of bare-metal stents were used in the PCI group, the findings may not be applicable to newer-generation stents.