Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data

Stuart J. Head, Milan Milojevic, Joost Daemen, Jung Min Ahn, Eric Boersma, Evald H. Christiansen, Michael J. Domanski, Michael E. Farkouh, Marcus Flather, Valentin Fuster, Mark A. Hlatky, Niels R. Holm, Whady A. Hueb, Masoor Kamalesh, Young Hak Kim, Timo Mäkikallio, Friedrich W. Mohr, Grigorios Papageorgiou, Seung Jung Park, Alfredo E. RodriguezJoseph F. Sabik, Rodney H. Stables, Gregg W. Stone, Patrick W. Serruys, Arie Pieter Kappetein

Research output: Contribution to journalArticle

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Abstract

Background: Numerous randomised trials have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for patients with coronary artery disease. However, no studies have been powered to detect a difference in mortality between the revascularisation strategies. Methods: We did a systematic review up to July 19, 2017, to identify randomised clinical trials comparing CABG with PCI using stents. Eligible studies included patients with multivessel or left main coronary artery disease who did not present with acute myocardial infarction, did PCI with stents (bare-metal or drug-eluting), and had more than 1 year of follow-up for all-cause mortality. In a collaborative, pooled analysis of individual patient data from the identified trials, we estimated all-cause mortality up to 5 years using Kaplan-Meier analyses and compared PCI with CABG using a random-effects Cox proportional-hazards model stratified by trial. Consistency of treatment effect was explored in subgroup analyses, with subgroups defined according to baseline clinical and anatomical characteristics. Findings: We included 11 randomised trials involving 11 518 patients selected by heart teams who were assigned to PCI (n=5753) or to CABG (n=5765). 976 patients died over a mean follow-up of 3·8 years (SD 1·4). Mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score was 26·0 (SD 9·5), with 1798 (22·1%) of 8138 patients having a SYNTAX score of 33 or higher. 5 year all-cause mortality was 11·2% after PCI and 9·2% after CABG (hazard ratio [HR] 1·20, 95% CI 1·06–1·37; p=0·0038). 5 year all-cause mortality was significantly different between the interventions in patients with multivessel disease (11·5% after PCI vs 8·9% after CABG; HR 1·28, 95% CI 1·09–1·49; p=0·0019), including in those with diabetes (15·5% vs 10·0%; 1·48, 1·19–1·84; p=0·0004), but not in those without diabetes (8·7% vs 8·0%; 1·08, 0·86–1·36; p=0·49). SYNTAX score had a significant effect on the difference between the interventions in multivessel disease. 5 year all-cause mortality was similar between the interventions in patients with left main disease (10·7% after PCI vs 10·5% after CABG; 1·07, 0·87–1·33; p=0·52), regardless of diabetes status and SYNTAX score. Interpretation: CABG had a mortality benefit over PCI in patients with multivessel disease, particularly those with diabetes and higher coronary complexity. No benefit for CABG over PCI was seen in patients with left main disease. Longer follow-up is needed to better define mortality differences between the revascularisation strategies. Funding: None.

Original languageEnglish (US)
JournalThe Lancet
DOIs
StateAccepted/In press - Jan 1 2018
Externally publishedYes

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Percutaneous Coronary Intervention
Coronary Artery Bypass
Coronary Artery Disease
Mortality
Stents
Taxus
Kaplan-Meier Estimate
Proportional Hazards Models
Thoracic Surgery
Randomized Controlled Trials
Metals
Myocardial Infarction

ASJC Scopus subject areas

  • Medicine(all)

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Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease : a pooled analysis of individual patient data. / Head, Stuart J.; Milojevic, Milan; Daemen, Joost; Ahn, Jung Min; Boersma, Eric; Christiansen, Evald H.; Domanski, Michael J.; Farkouh, Michael E.; Flather, Marcus; Fuster, Valentin; Hlatky, Mark A.; Holm, Niels R.; Hueb, Whady A.; Kamalesh, Masoor; Kim, Young Hak; Mäkikallio, Timo; Mohr, Friedrich W.; Papageorgiou, Grigorios; Park, Seung Jung; Rodriguez, Alfredo E.; Sabik, Joseph F.; Stables, Rodney H.; Stone, Gregg W.; Serruys, Patrick W.; Kappetein, Arie Pieter.

In: The Lancet, 01.01.2018.

Research output: Contribution to journalArticle

Head, SJ, Milojevic, M, Daemen, J, Ahn, JM, Boersma, E, Christiansen, EH, Domanski, MJ, Farkouh, ME, Flather, M, Fuster, V, Hlatky, MA, Holm, NR, Hueb, WA, Kamalesh, M, Kim, YH, Mäkikallio, T, Mohr, FW, Papageorgiou, G, Park, SJ, Rodriguez, AE, Sabik, JF, Stables, RH, Stone, GW, Serruys, PW & Kappetein, AP 2018, 'Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data', The Lancet. https://doi.org/10.1016/S0140-6736(18)30423-9
Head, Stuart J. ; Milojevic, Milan ; Daemen, Joost ; Ahn, Jung Min ; Boersma, Eric ; Christiansen, Evald H. ; Domanski, Michael J. ; Farkouh, Michael E. ; Flather, Marcus ; Fuster, Valentin ; Hlatky, Mark A. ; Holm, Niels R. ; Hueb, Whady A. ; Kamalesh, Masoor ; Kim, Young Hak ; Mäkikallio, Timo ; Mohr, Friedrich W. ; Papageorgiou, Grigorios ; Park, Seung Jung ; Rodriguez, Alfredo E. ; Sabik, Joseph F. ; Stables, Rodney H. ; Stone, Gregg W. ; Serruys, Patrick W. ; Kappetein, Arie Pieter. / Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease : a pooled analysis of individual patient data. In: The Lancet. 2018.
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abstract = "Background: Numerous randomised trials have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for patients with coronary artery disease. However, no studies have been powered to detect a difference in mortality between the revascularisation strategies. Methods: We did a systematic review up to July 19, 2017, to identify randomised clinical trials comparing CABG with PCI using stents. Eligible studies included patients with multivessel or left main coronary artery disease who did not present with acute myocardial infarction, did PCI with stents (bare-metal or drug-eluting), and had more than 1 year of follow-up for all-cause mortality. In a collaborative, pooled analysis of individual patient data from the identified trials, we estimated all-cause mortality up to 5 years using Kaplan-Meier analyses and compared PCI with CABG using a random-effects Cox proportional-hazards model stratified by trial. Consistency of treatment effect was explored in subgroup analyses, with subgroups defined according to baseline clinical and anatomical characteristics. Findings: We included 11 randomised trials involving 11 518 patients selected by heart teams who were assigned to PCI (n=5753) or to CABG (n=5765). 976 patients died over a mean follow-up of 3·8 years (SD 1·4). Mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score was 26·0 (SD 9·5), with 1798 (22·1{\%}) of 8138 patients having a SYNTAX score of 33 or higher. 5 year all-cause mortality was 11·2{\%} after PCI and 9·2{\%} after CABG (hazard ratio [HR] 1·20, 95{\%} CI 1·06–1·37; p=0·0038). 5 year all-cause mortality was significantly different between the interventions in patients with multivessel disease (11·5{\%} after PCI vs 8·9{\%} after CABG; HR 1·28, 95{\%} CI 1·09–1·49; p=0·0019), including in those with diabetes (15·5{\%} vs 10·0{\%}; 1·48, 1·19–1·84; p=0·0004), but not in those without diabetes (8·7{\%} vs 8·0{\%}; 1·08, 0·86–1·36; p=0·49). SYNTAX score had a significant effect on the difference between the interventions in multivessel disease. 5 year all-cause mortality was similar between the interventions in patients with left main disease (10·7{\%} after PCI vs 10·5{\%} after CABG; 1·07, 0·87–1·33; p=0·52), regardless of diabetes status and SYNTAX score. Interpretation: CABG had a mortality benefit over PCI in patients with multivessel disease, particularly those with diabetes and higher coronary complexity. No benefit for CABG over PCI was seen in patients with left main disease. Longer follow-up is needed to better define mortality differences between the revascularisation strategies. Funding: None.",
author = "Head, {Stuart J.} and Milan Milojevic and Joost Daemen and Ahn, {Jung Min} and Eric Boersma and Christiansen, {Evald H.} and Domanski, {Michael J.} and Farkouh, {Michael E.} and Marcus Flather and Valentin Fuster and Hlatky, {Mark A.} and Holm, {Niels R.} and Hueb, {Whady A.} and Masoor Kamalesh and Kim, {Young Hak} and Timo M{\"a}kikallio and Mohr, {Friedrich W.} and Grigorios Papageorgiou and Park, {Seung Jung} and Rodriguez, {Alfredo E.} and Sabik, {Joseph F.} and Stables, {Rodney H.} and Stone, {Gregg W.} and Serruys, {Patrick W.} and Kappetein, {Arie Pieter}",
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TY - JOUR

T1 - Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease

T2 - a pooled analysis of individual patient data

AU - Head, Stuart J.

AU - Milojevic, Milan

AU - Daemen, Joost

AU - Ahn, Jung Min

AU - Boersma, Eric

AU - Christiansen, Evald H.

AU - Domanski, Michael J.

AU - Farkouh, Michael E.

AU - Flather, Marcus

AU - Fuster, Valentin

AU - Hlatky, Mark A.

AU - Holm, Niels R.

AU - Hueb, Whady A.

AU - Kamalesh, Masoor

AU - Kim, Young Hak

AU - Mäkikallio, Timo

AU - Mohr, Friedrich W.

AU - Papageorgiou, Grigorios

AU - Park, Seung Jung

AU - Rodriguez, Alfredo E.

AU - Sabik, Joseph F.

AU - Stables, Rodney H.

AU - Stone, Gregg W.

AU - Serruys, Patrick W.

AU - Kappetein, Arie Pieter

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background: Numerous randomised trials have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for patients with coronary artery disease. However, no studies have been powered to detect a difference in mortality between the revascularisation strategies. Methods: We did a systematic review up to July 19, 2017, to identify randomised clinical trials comparing CABG with PCI using stents. Eligible studies included patients with multivessel or left main coronary artery disease who did not present with acute myocardial infarction, did PCI with stents (bare-metal or drug-eluting), and had more than 1 year of follow-up for all-cause mortality. In a collaborative, pooled analysis of individual patient data from the identified trials, we estimated all-cause mortality up to 5 years using Kaplan-Meier analyses and compared PCI with CABG using a random-effects Cox proportional-hazards model stratified by trial. Consistency of treatment effect was explored in subgroup analyses, with subgroups defined according to baseline clinical and anatomical characteristics. Findings: We included 11 randomised trials involving 11 518 patients selected by heart teams who were assigned to PCI (n=5753) or to CABG (n=5765). 976 patients died over a mean follow-up of 3·8 years (SD 1·4). Mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score was 26·0 (SD 9·5), with 1798 (22·1%) of 8138 patients having a SYNTAX score of 33 or higher. 5 year all-cause mortality was 11·2% after PCI and 9·2% after CABG (hazard ratio [HR] 1·20, 95% CI 1·06–1·37; p=0·0038). 5 year all-cause mortality was significantly different between the interventions in patients with multivessel disease (11·5% after PCI vs 8·9% after CABG; HR 1·28, 95% CI 1·09–1·49; p=0·0019), including in those with diabetes (15·5% vs 10·0%; 1·48, 1·19–1·84; p=0·0004), but not in those without diabetes (8·7% vs 8·0%; 1·08, 0·86–1·36; p=0·49). SYNTAX score had a significant effect on the difference between the interventions in multivessel disease. 5 year all-cause mortality was similar between the interventions in patients with left main disease (10·7% after PCI vs 10·5% after CABG; 1·07, 0·87–1·33; p=0·52), regardless of diabetes status and SYNTAX score. Interpretation: CABG had a mortality benefit over PCI in patients with multivessel disease, particularly those with diabetes and higher coronary complexity. No benefit for CABG over PCI was seen in patients with left main disease. Longer follow-up is needed to better define mortality differences between the revascularisation strategies. Funding: None.

AB - Background: Numerous randomised trials have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for patients with coronary artery disease. However, no studies have been powered to detect a difference in mortality between the revascularisation strategies. Methods: We did a systematic review up to July 19, 2017, to identify randomised clinical trials comparing CABG with PCI using stents. Eligible studies included patients with multivessel or left main coronary artery disease who did not present with acute myocardial infarction, did PCI with stents (bare-metal or drug-eluting), and had more than 1 year of follow-up for all-cause mortality. In a collaborative, pooled analysis of individual patient data from the identified trials, we estimated all-cause mortality up to 5 years using Kaplan-Meier analyses and compared PCI with CABG using a random-effects Cox proportional-hazards model stratified by trial. Consistency of treatment effect was explored in subgroup analyses, with subgroups defined according to baseline clinical and anatomical characteristics. Findings: We included 11 randomised trials involving 11 518 patients selected by heart teams who were assigned to PCI (n=5753) or to CABG (n=5765). 976 patients died over a mean follow-up of 3·8 years (SD 1·4). Mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score was 26·0 (SD 9·5), with 1798 (22·1%) of 8138 patients having a SYNTAX score of 33 or higher. 5 year all-cause mortality was 11·2% after PCI and 9·2% after CABG (hazard ratio [HR] 1·20, 95% CI 1·06–1·37; p=0·0038). 5 year all-cause mortality was significantly different between the interventions in patients with multivessel disease (11·5% after PCI vs 8·9% after CABG; HR 1·28, 95% CI 1·09–1·49; p=0·0019), including in those with diabetes (15·5% vs 10·0%; 1·48, 1·19–1·84; p=0·0004), but not in those without diabetes (8·7% vs 8·0%; 1·08, 0·86–1·36; p=0·49). SYNTAX score had a significant effect on the difference between the interventions in multivessel disease. 5 year all-cause mortality was similar between the interventions in patients with left main disease (10·7% after PCI vs 10·5% after CABG; 1·07, 0·87–1·33; p=0·52), regardless of diabetes status and SYNTAX score. Interpretation: CABG had a mortality benefit over PCI in patients with multivessel disease, particularly those with diabetes and higher coronary complexity. No benefit for CABG over PCI was seen in patients with left main disease. Longer follow-up is needed to better define mortality differences between the revascularisation strategies. Funding: None.

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