Efficacy of CABG vs. Percutaneous Coronary Intervention

Efficacy of CABG vs. Percutaneous Coronary Intervention


CABG increases rates of relief of angina (NNT 12 at 1 year, NNT 20 at 5 years) and decreases rates of repeat revascularization (NNT 5 at 1 year, NNT 3 at 5 years) compared to percutaneous coronary intervention (PCI), but no difference in overall survival (level 1 [likely reliable] evidence), based on a systematic review of 23 randomized trials in 9,963 patients. CABG increased 30-day risk of stroke (NNH 167). PCI included balloon angioplasty or stents in most trials; only 1 small trial used drug-eluting stents



(Ann Intern Med 2007 Nov 20;147(10):early online full-text, AHRQ Comparative Effectiveness Review 2007 Oct:9 PDF).



Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery

Bravata DM, Gienger AL, McDonald KM, Sundaram V, Perez MV, Varghese R, Kapoor JR, Ardehali R, Owens DK, Hlatky MA.


the Center for Primary Care and Outcomes Research and Stanford University School of Medicine, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California


20 November 2007 Volume 147 Issue 10


Background: The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood.


Purpose: To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated.


Data Sources: MEDLINE, EMBASE, and Cochrane databases (1966–2006); conference proceedings; and bibliographies of retrieved articles.


Study Selection: Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.


Data Extraction: Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.


Data Synthesis: We identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedural strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG–PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.


Limitations: The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.


Conclusion: Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures.


Editors' Notes

Context

The relative benefits and harms of coronary artery bypass surgery (CABG) versus percutaneous coronary intervention (PCI) are sometimes unclear.


Contribution

This systematic review of 23 randomized trials found that survival at 10 years was similar for CABG and PCI, even among diabetic patients. Procedural strokes and angina relief were more common after CABG (risk difference, 0.6% and about 5% to 8%, respectively), whereas repeated revascularization procedures were more common after PCI (risk difference, 24% at 1 year).


Caution

Only 1 small trial used drug-eluting stents, and Few patients with extensive coronary disease or poor ventricular function were enrolled.