CABG trumps PCI in multivessel CAD patients

Coronary artery bypass grafting (CABG) surgery beat out stent placement with percutaneous coronary intervention (PCI) in a recent study of patients with multivessel coronary artery disease. Patients saw lower risks of death, hospital readmission and revascularization with the former procedure.

CABG is the most commonly performed heart operation in the U.S., lead investigator Suresh R. Mulukutla, MD, of the University of Pittsburgh Medical Center (UPMC) in Pennsylvania, said in a release. Recent trends have favored PCI over open-heart surgery because it’s less invasive. As a result, CABG is often reserved for a select population of patients with multi-vessel disease: those who also present with diabetes and weaker ventricles.

“The last several years have seen a shift toward more PCI over CABG,” Mulukutla said. “While there may be valid reasons for this, our data—which show CABG outperforming PCI in almost every patient group—should push us to further discuss all of the options.”

Mulukutla and his team pulled data from the Society of Thoracic Surgeons National Database and the American College of Cardiology Foundation National Cardiovascular Data Registry to identify patients who underwent CABG or PCI between 2010 and 2018 at UPMC. Eligible patients were sorted into two groups, with 844 patients undergoing CABG and 844 opting for PCI.

Estimated one-year mortality rates were 7.2% in the CABG group and 11.5% in the PCI group, the authors reported. CABG patients also saw a lower risk of hospital readmissions than their counterparts (28.1% compared to 38.4%, respectively), and lower rates of revascularization (1% compared to 6.7%).

“Our data demonstrate a significant mortality benefit with CABG over PCI, and this benefit is consistent across virtually all major patient groups, suggesting that CABG should be considered in broader patient populations, not just in cases of patients with diabetes and left ventricular dysfunction, which is what is commonly practiced,” Mulukutla said.

He said the CABG vs. PCI decision should be made with the assistance of a full heart team, which typically involves cardiothoracic surgeons, cardiologists and other experts, but heart team input can be limited when it comes to revascularization. PCI can be completed at the time of a patient’s diagnostic procedure, leaving little room to discuss treatment options with a team.

Mulukutla noted his team is working to better integrate heart teams into decision-making to “overcome some of the limitations given the current infrastructure of how these decisions are made.” He said they’re also applying their recent findings to identify specific patient populations who might benefit most from either CABG or PCI.

“A major point in the study is the focus on the current era of revascularization with the most currently available stents,” he said. “This research is really a modern, ‘real-world’ experience. While randomized clinical trials are clearly important, real-world analyses also can be very instructive because they provide insights on how we are making clinical decisions.”

Mulukutla et al.’s work was published in The Annals of Thoracic Surgery May 1.