ASCERT: Long-term Results Favor CABG Over PCI for Multivessel Disease


Within 4 years after revascularization, patients with multivessel disease who receive percutaneous coronary intervention (PCI) experience fewer strokes while those who undergo coronary artery bypass graft (CABG) surgery have fewer myocardial infarctions (MIs) and a lower composite rate of stroke, MI, and death, according to a subanalysis of the ASCERT trial. The findings were presented January 29, 2013, at the Society of Thoracic Surgeons Annual Meeting in Los Angeles, CA.

The main ASCERT (American College of Cardiology [ACC] Foundation - Society of Thoracic Surgeons [STS] Collaboration on the Comparative Effectiveness of Revascularization sTrategies) trial, published in the New England Journal of Medicine, showed a long-term survival advantage with CABG over PCI. The study linked the ACC’s NCDR CathPCI registry and the STS database with claims data from the Centers for Medicare and Medicaid Services to assess patients receiving PCI (n = 103,549) or CABG (n = 86,244) from 2004 through 2007.

In a subanalysis, Frank H. Edwards, MD, of the University of Florida (Jacksonville, FL), and colleagues looked at a composite endpoint of stroke, MI, and death. Event rates in the first year favored PCI, but CABG was favored for the next 3 years, yielding a cumulative advantage (table 1).

Table 1. Outcomes at 4 Years

 

CABG
(n = 86,244)

PCI
(n = 103,549)

RR

Stroke, MI, Death

21.6%

26.7%

0.81

Stroke

4.5%

3.1%

1.43

MI

3.2%

6.6%

0.49


The researchers noted that the overall stroke advantage for PCI was primarily driven by a higher rate for CABG during the first 30 days (1.55% vs. 0.37% for PCI).

Results Support ‘Heart Team’ Approach

“ASCERT showed that in the first few months after the procedure, results favored PCI, but long-term data demonstrated a clear overall advantage for CABG,” Dr. Edwards said in a press release. “The benefits of CABG progressively increase over time, demonstrating the long-term durability of the procedure.”

Other nonfatal outcomes should be considered in addition to survival, he continued. “These new ASCERT results reinforce the need for a ‘heart team’ approach to ensure that the patient is fully informed of the most likely outcomes when determining the best treatment for multivessel disease,” Dr. Edwards said. “The heart team should include a cardiac surgeon, a cardiologist, and the patient.”

In an e-mail communication with TCTMD, Gregg W. Stone, MD, of Columbia University Medical Center/NewYork-Presbyterian Hospital (New York, NY), said the data “are consistent with the overall results of other recent CABG vs. PCI randomized trials, such as SYNTAX and FREEDOM.” Since “most of the MIs [have no] prognostic significance, the most important endpoints are death, stroke and QOL,” he added.

However, the study does not take into account “advances in PCI including FFR guidance and best-in-class DES, which collectively can reduce MACE by 50%,” Dr. Stone noted. In addition, the researchers did not consider anatomic complexity [and] “noncomplex patients can clearly be treated with PCI with excellent outcomes,” Dr. Stone added.

Patient personal preference must be strongly considered because the absolute event rate differences are “not huge,” Dr. Stone observed, adding that he strongly supports the heart team approach to help patients make the most informed decision.

 


Source:
Edwards, FH. Composite analysis of 189,793 Medicare patients with multi-vessel coronary disease demonstrates a long-term advantage for CABG compared to stent placement. Presented at: Society of Thoracic Surgeons 49th Annual Meeting; January 28, 2013; Los Angeles, CA.

 

 

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Disclosures
  • Dr. Edwards reports no relevant conflicts of interest.
  • Dr. Stone reports receiving consulting fees/honoraria from Abbott Vascular, Atrium, Boston Scientific, Inspire MD, and Medtronic.

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