Stroke rates are higher in the first 30 days after coronary artery bypass grafting (CABG) than percutaneous coronary intervention (PCI) but are similar thereafter, according to a pooled analysis of 11 randomized trials published July 16 in the Journal of the American College of Cardiology.
Overall, stroke occurred in 2.6 percent of PCI patients and 3.2 percent of CABG patients at five years of follow-up, but that difference was driven entirely by the rates at 30 days (0.4 percent for PCI and 1.1 percent for CABG).
“The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes,” noted lead author Stuart J. Head, MD, PhD, and colleagues. “More studies are needed on strategies to prevent perioperative stroke in patients undergoing CABG surgery.”
The researchers said their results are consistent with individual trials, but most of those lacked the statistical power to detect meaningful differences between stroke rates because the events are relatively rare. By combining patient-level data from randomized trials evaluating the revascularization strategies, they were able to build a sample size of about 5,750 patients undergoing each type of intervention.
The average age of the study population was 63.6 years, and 24 percent of patients were female. Patient characteristics were similar between treatment groups.
Unsurprisingly, periprocedural strokes were associated with worse long-term survival, regardless if the patient suffered the event following PCI or CABG. Five-year mortality rates exceeded 40 percent in both groups if patients experienced stroke, but were about 10 percent for those who didn’t.
Despite the lower incidence of stroke associated with PCI, CABG was linked to a lower five-year occurrence of either all-cause mortality or stroke (13 percent versus 11.4 percent)—although that difference didn’t reach statistical significance. In subgroup analyses, CABG conferred a benefit in that composite endpoint for patients with diabetes and multivessel disease, but not left-main disease.
“Typically, nondiabetic patients with anatomically straightforward CAD (coronary artery disease) are offered PCI, and the current paper by Head et al. provides further data regarding the rationale for this strategy based on both long-term survival outcomes as well as the reduced risk for stroke in the short and long term,” wrote Amar Krishnaswamy, MD, and Samir R. Kapadia, MD—both with the Cleveland Clinic—in a related editorial.
“However, for patients with diabetes or those with multivessel complex CAD … a thorough shared decision-making conversation, close clinical follow-up after revascularization to diagnose and medically manage stroke risk factors, and referral to centers experienced in stroke-minimization CABG strategies (when clinically indicated) is important to navigate to the best patient outcomes.”
Head and colleagues listed the following among the limitations of their study: techniques for both interventions changed during the inclusion period (1995-2015), the severity of strokes wasn’t captured and postprocedural medication regimens weren’t defined.
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.