SYNTAX Left Main: PCI Provides Similar Angina Relief to CABG at Lower Cost

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NEW YORK—Fresh results from the SYNTAX trial show that patients undergoing revascularization for unprotected left main disease receive comparable angina relief from either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Moreover, the higher device-related and follow-up costs seen with PCI are cancelled out by increased hospital costs associated with CABG, such that stenting is less expensive overall.

David J. Cohen, MD, MSc, of Saint Luke’s Mid America Heart and Vascular Institute (Kansas City, MO), presented late breaking findings from the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial’s left main cohort on Monday, February 14, 2011, at the Left Main Coronary Interventions Course.

SYNTAX employed an all-comers design that involved 3,075 consecutive patients with triple vessel or left main disease at 85 sites in 17 countries. Each patient was evaluated by a local interventional cardiologist and cardiac surgeon; those deemed equally suitable for either surgical or percutaneous treatment (n = 1,800) were randomized to undergo CABG or PCI with paclitaxel-eluting Taxus stents (Boston Scientific, Natick, MA).

The overall results of SYNTAX showed that early recovery is much better with PCI but CABG provides slightly better angina relief, especially in patients who were highly symptomatic at baseline, Dr. Cohen reported. The cost-effectiveness of PCI vs. CABG mainly depends on angiographic complexity as determined by the Syntax score.

The new results represent the first time such issues have been considered specifically in the left main cohort of 705 patients, he said.

Quality and Quantity

As in the overall trial, the current analysis measured quality of life according to the Seattle Angina Questionnaire (SAQ). Costs were calculated from the perspective of the US health care system for all patients regardless of where they actually underwent treatment.

Baseline quality-of-life data were similar for left main patients whether they were treated with PCI (n =357) or CABG (n =348); approximately 40% had fairly severe angina that occurred daily or weekly but slightly over 20% were asymptomatic.

At 1 month after revascularization, both treatment groups reported reduced angina frequency but the degree of improvement was higher in PCI patients, amounting to an absolute difference between the PCI and CABG groups of 3.8 on the SAQ scale (P = 0.02). By 6 months, this difference had disappeared, such that by 12 months left main patients derived similar angina relief from either treatment; nearly 60% of patients in each group reported substantial improvement (≥ 20 points vs. baseline on the SAQ scale).

“I think overall in terms of angina—cardiac-specific quality of life—it is very reassuring that for PCI we are providing very comparable outcomes to what we see with bypass surgery,” Dr. Cohen said, adding that more general measurements of physical and mental health also were equivalent between treatments despite the higher need for repeat revascularization with PCI. This reflects “the much easier recovery that all of our patients know and really is one of the main reasons why they come to us for PCI compared to bypass surgery.”

Both PCI and CABG held an economic advantage during different phases of treatment. Despite the added expense of stents, initial hospitalization costs were approximately $8,000 lower for PCI vs. CABG thanks to disparities in length of stay, complications, and physician costs (figure 1). But 1-year follow-up costs were nearly $2,000 lower for CABG, mainly due to increases in repeat revascularization and outpatient medication use after PCI (figure 2). 

Total costs within the first year topped out at $39,538 for CABG and $33,196 for PCI, a difference of $6,341 (P < 0.001). PCI also offered better quality-adjusted life expectancy within 1 year than CABG.

PCI Cheaper, Simpler in Left Main

Dr. Cohen noted that PCI procedures for the left main cohort were less costly and required fewer resources compared with the overall SYNTAX population, which also included patients with triple-vessel disease. Subsequent revascularization procedures after PCI were less common in the left main group than in the triple-vessel group, leading to a lower downstream follow-up cost. Upfront costs also were less in the left main cohort, because these patients required fewer DES and needed staged procedures less frequently (table 1).

Table 1. SYNTAX: Left Main vs. Triple-Vessel Disease PCI


Left Main Cohort

Triple-Vessel Cohort

Follow-up Cost



Mean Procedure Cost



Mean Number of DES



Need for Staged Procedures



Five-year results from SYNTAX will show whether the increased follow-up costs for PCI vs. CABG in the left main group persist after 1 year, Dr. Cohen noted. The recently launched EXCEL trial comparing everolimus-eluting stents vs. CABG in approximately 2,500 patients with left main disease, “should be able to provide relatively definitive cost-effectiveness data for both the overall population and importantly for key subgroups,” he added.

Speaking after the presentation, Martin B. Leon, MD, of Columbia University Medical Center (New York, NY), reported that US practitioners were moving towards more staged procedures as a means of achieving more complete revascularization. He questioned whether an increase in staging would diminish the economic advantage of PCI.

It is “a little hard to speculate,” Dr. Cohen replied. But he pointed out that the 14.1% prevalence of staged procedures in the PCI arm of the overall SYNTAX trial did not compromise the results very much. “I think if we stay in the range of 15 to 20 [percent], we’re probably going to be OK. I wouldn’t want to see it creep a lot further than that,” he said. “The number of stents is a big factor here. If it takes 5, 6, or 7 drug-eluting stents to do a case, that drives the cost up frankly more than the staging.”

For his part, Dr. Leon predicted that the “striking difference” in cost effectiveness shown by the current analysis will give a major boost to left main PCI. “I think people are going to react to that,” he said. Dr. Cohen agreed, noting that one of the major revelations of SYNTAX has been how well PCI performs in left main disease for both clinical and economic outcomes.


Cohen DJ. Health related quality of life and cost-effectiveness of DES vs. CABG for left main disease: 1-year results from the SYNTAX trial. Presented at: Left Main Coronary Interventions Course; February 14, 2011; New York, NY.



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  • Dr. Cohen reports financial relationships with several drug and device companies.