CABG Achieves Better 30-Day Outcomes vs PCI in Younger Patients, Similar 5-year Mortality

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Patients age 50 or younger have excellent and comparable immediate outcomes after undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with similar long-term survival, according to a study published online May 5, 2014, ahead of print in the American Journal of Cardiology. However, for patients with ST-segment elevation myocardial infarction (STEMI), long-term survival was better with PCI.

For the CRAGS (The Coronary aRtery diseAse in younG adultS) study, Fausto Biancari, MD, PhD, of Oulu University Hospital (Oulu, Finland), and colleagues retrospectively enrolled 2,209 consecutive patients (≤ 50 years) from 15 European hospitals who underwent CABG (n = 592) or PCI (n = 1,617) between 2002 and 2012.

PCI was associated with a trend toward better 5-year survival than CABG but higher rates of MACCE, MI, and repeat revascularization (table 1). Propensity-score adjusted multivariate analysis confirmed the results.

Table 1. Outcomes: PCI vs CABG

 

PCI
(n = 1,617)

CABG
(n = 592)

Univariate P Value

30 Days
Mortality
Repeat Revascularization
Stroke

 
0.8%
2.2%
0

 
1.4%
1.2%
0.7%

 
.27
.13
.005

5 Years
Survival
Freedom from Repeat Revascularization
Freedom from Stroke
Freedom from MI
Freedom from MACCE

 
97.8%
77.6%
98.0%
89.9%
73.9%

 
94.9%
92.5%
98.0%
96.6%
85.0%

 
.08
< .0001
.73
< .0001
< .0001


In patients with multivessel disease, PCI and CABG were associated with similar 5-year survival (98.0% vs 94.9%; P = .221) and freedom from stroke (98.0% vs 97.9%; P = .850). However, PCI was associated with lower freedom from MACCE, MI, and repeat revascularization at 5 years compared with CABG (P < .0001 for all).

Likewise, PCI was associated with similar 5-year survival as CABG in diabetic patients (93.5% vs 90.5%; P = .613) but lower freedom from MACCE (P < .0001), MI (P = .004), stroke (P = .035), and repeat revascularization (P < .0001).

On the other hand, in STEMI patients, PCI was linked with better 5-year survival than CABG (97.5% vs 88.8%; P = .001). This was driven by lower 30-day mortality after PCI than CABG (1.5% vs 6.0%; P = .017). In these patients, similar rates of MACCE and MI were observed, but the risk of repeat revascularization tended to be higher after PCI than CABG (81.1% vs 91.1%; P = .065).

Results Uphold Current Guidelines

“These findings are in line with those of the SYNTAX study,” Dr. Biancari and colleagues write, adding that “the differences between the study groups were more pronounced in the subset of patients with two- to three-vessel disease as well as in patients with stable coronary artery disease.”

Therefore, the findings “support the current guidelines recommending CABG in patients with two- to three-vessel disease and diabetes,” they continue. However, “it remains to be seen whether wider use of the new-generation drug-eluting stents will provide better protection against repeat revascularizations after PCI and reduce the currently high rate of stent thrombosis.”

Although the authors acknowledge the inherent limitations of a retrospective study, “a prospective study on this issue would be hardly feasible because of the limited number of young patients yearly treated in each center,” they say. Longer follow-up would be beneficial, but caution should be given to the bias introduced when data collected on patients treated with older PCI technology is assessed, Dr. Biancari and colleagues warn.

Study Details

Patients who underwent PCI were younger, more likely to be smokers, and less likely to have diabetes and multivessel disease than those who had CABG. Additionally, almost half (45.7%) of PCI-treated patients were diagnosed with STEMI, compared with only 14.2% of CABG-treated patients. Only 50.9% of patients underwent PCI with DES.

 


Source:
Biancari F, Gudbjartsson T, Heikkinen J, et al. Comparison of 30-day and 5-year outcome of percutaneous coronary intervention versus coronary artery bypass grafting in patients aged ≤ 50 years (The Coronary aRtery diseAse in younG adultS study). Circulation. 2014;Epub ahead of print.

 

 

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Disclosures
  • The study was funded by the Finnish Foundation for Cardiovascular Research.
  • The paper contains no statement of conflict for Dr. Biancari.

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