PCI vs. CABG a Close Call in Some Complex Patients

San Francisco, CA—SYNTAX and other randomized trials have closely examined the proper roles of PCI and CABG in patients with triple-vessel and left main disease. In a presentation at TCT 2013, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center in New York, N.Y., provided an interpretation of the data and examined the factors that play into both clinicians’ and patients’ choice of therapy.

In the landmark SYNTAX trial, CABG was superior to paclitaxel-eluting stents (Taxus, Boston Scientific) with respect to MACCE over 5 years. While the difference was largely driven by increased repeat revascularization, the incidence of excess cardiac death and MI and stent thrombosis with PCI was troubling. 

“There should be no question about interpretation: CABG is favored over the first-generation Taxus stent,” Kirtane said. He noted, however, that within the first year PCI reduced stroke. Also, although quality of life was similar between PCI and surgery out to 1 year, because PCI is less invasive, it provides additional benefits.

Risk stratification can help determine if one strategy may be preferred in various subgroups, and that is where Syntax scores should be considered, Kirtane noted. In three-vessel disease, among patients with scores in the lower tertile (0-22), it is difficult to differentiate between therapies, whereas in the intermediate (23-32) and higher (≥33) tertiles, CABG remains superior. When Syntax II scores are applied, CABG is favored in 84.2% of the population, and PCI in only 15.8%. And even among patients with low Syntax I scores, PCI is favored in only 29.1%. 

In left main disease, overall MACCE was similar between PCI and CABG, although in those with less complex disease, the data favored PCI to some extent, he said. When the Syntax II score is applied, there are more scenarios that favor PCI over CABG: 62.8% in the lower tertile, 61.7% in the intermediate tertile, and 31.8% in the highest tertile. Nonetheless, CABG remains the standard of care, Kirtane concluded.

The choice for diabetic patients 

The recent FREEDOM trial, which enrolled 1,900 patients with diabetes and multivessel disease, demonstrated the superiority of CABG over first-generation DES.

Although interaction with Syntax score was negative, Kirtane said most clinicians believe it affects outcomes.

Overall, CABG has several advantages: it is a durable procedure with data on its side, in which complete and difficult revascularization is more achievable, medical compliance and adherence are less of an issue, and provided a patient is not frail, surgical risk scores are good. 

Kirtane offered a checklist of factors that may influence of one therapy over the other in particular patient (see Figure).

Since the SYNTAX and FREEDOM trials, PCI has clearly improved with use of second- and third-generation DES. However, a recent analysis of SYNTAX data determined that even if definite and probable stent thrombosis were eliminated, cardiac death would be reduced by only 1.5%, suggesting that the mortality disparity between CABG and PCI is unlikely to be erased by better technology, Kirtane said.

Disclosures: 

Kirtane reports no relevant conflicts of interest.