PCI vs. CABG: is age selection for left major coronary artery disease?

BOSTON – Adding to the debate about left primary disease revascularization, patients had better survival after coronary artery bypass graft (CABG) surgery than percutaneous coronary intervention (PCI) in a nationwide enrollment study.

All-cause mortality remained greater up to 7 years after PCI versus CABG (adjusted heart rate 1.59, 95% CI 1.11-2.27) although different analytical methods were used to explain the confusion in the Swedish coronary angiography and angioplasty registry (SCAAR), according to Elmir Omirovic, MD, PhD, of Sahlgrenska University Hospital in Gothenburg, Sweden.

However, in the subgroup analysis, there was a significant interaction by age, such that subjects 80 years of age or older lived longer after PCI for left primary disease, while younger patients fare better with surgery, Omirovich reported. in Cardiovascular treatments via catheterization TCT meeting hosted by the Cardiovascular Research Foundation (CRF).

Results by median survival time indicated that patients expected to live at least 7 years gained an average of 6 months with CABG rather than PCI; For those with a shorter life expectancy, the estimated prolongation of life was less than 1 month.

The take-home message is that surgeons should not operate on older, high-risk patients with left primary disease, Omerovic said, adding another point to the discussion about stenting versus surgery on a left major CAD chart.

while the 2016 Nobel trial results CABG preferred, and EXCEL experience He concluded that there is not much difference between the strategies. Controversy erupted when a prominent EXCEL investigator separated from the group in 2019 and I cried foul At the expense of the unfair trial of 0f periprocedural MIs that put surgery at a disadvantage.

Then, in a dimensional analysis Pooling these two trials with SYNTAX and PRECOMBAT, the investigators determined that there was no statistically significant difference in 5 years of all-cause death between PCI and CABG, although Bayesian analysis suggested a slightly greater longevity after CABG.

“The question has not been resolved and I think we will continue to discuss it for years to come,” Omirovic told TCT’s press conference.

Omerovic reported that the 30 hospitals participating in SCAAR were roughly divided between those performing more CABG and those with more CABG.

All subjects in Sweden with stable angina, unstable angina, and unstable angina MI (NSTEMI) who underwent coronary angiography since 2015 and left the primary disease (stenosis >50%) were included. The investigators found that these 10,254 individuals were roughly divided between those with PCI (52.6%) and those who underwent CABG (47.4%).

The two groups differed in essentially different ways. For example, subjects selected for PCI were a few years older and tended to present more hyperlipidemia, previous myocardial infarction, and previous revascularization procedures.

The possibility of selection bias was raised by Uri Ben-Yehuda, MD, a clinical trial expert at CRF, who said he observed an early disconnection of curves that surprisingly favored CABG despite the immediate risk of surgical complications.

“Your curves open instantly and so wide… It just feels a little bit nonsensical,” agreed TCT session speaker Davide New Year, MD, of Azienda Ospedaliero-Universitaria Policlinico-Vittorio Emanuele in Catania, Italy.

Omerovic explained that the study relied on instrumental variable analysis—using each participating hospital’s preference for PCI or CABG as a source of randomization—and inverted weighting of propensity scores to help control for bias and confusion.

Despite these efforts, it was acknowledged that selection bias and residual confusion could not be ruled out due to the observational nature of the study.

“You have the tools, the background, and the infrastructure to do exactly this randomized controlled trial, and that’s what needs to happen if you really want the answer,” commented Roxana Mehran, MD, TCT Press Conference, of Mount Sinai. New York City College of Medicine.

She added that cardiovascular mortality would be a useful end point for assessment in the setting of left primary revascularization.

  • Nicole Low She is a reporter at MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

Omarovich and Ben Yehuda did not disclose any relationship with the industry.

Capodanno disclosed his relationships with Amgen, Arena, Daiichi-Sankyo/ Eli Lilly, Sanofi-Aventis, and Terumo Medical, as well as an institutional relationship with Medtronic.

Mahran revealed multiple relationships with the industry.