September 13th, 2010

SYNTAX at 3 years: CABG Still Winning, but PCI Acceptable in Low-Risk Patients

Three-year outcomes from the SYNTAX trial continue to show the overall superiority of CABG over PCI in patients with complex disease, but they leave room for the use of PCI in patients with low-risk disease. The results of the trial were presented by A. Pieter Kappetein at the European Association of Cardio-Thoracic Surgery annual meeting in Geneva, Switzerland.

SYNTAX randomized 1800 patients with 3-vessel or left main disease to either surgery or PCI. In the initial 1-year results, published in the New England Journal of Medicine, the rate of major adverse cardiac or cardiovascular events (MACCE) was lower in the CABG group, largely driven by more repeat revascularizations with PCI. However, a higher rate of stroke in the CABG group, and better outcomes for PCI among patients with less complex disease, led many observers to conclude that the message was far from simple. A similar pattern was observed at 2 years.

Now, at 3 years, the rate of MACCE remains significantly higher in the PCI group than in the CABG group, again driven mostly by the higher repeat revascularization rate with PCI. In addition, in the second and third years of the trial, the investigators observed significantly higher MI rates in the PCI group, although the composite safety endpoint (death, CVA, MI) did not differ.

Here are some of the key 3-year data (CABG vs. PCI):

  • MACCE: 20.2% vs. 28.0%
  • Mortality: 6.7% vs. 8.6%
  • CVA: 3.4% vs. 2.0% (nearly all the difference occured in the first year)
  • MI: 3.6% vs. 7.1%
  • Repeat revascularization: 10.7% vs. 19.7%

Here is the yearly breakdown for MI:

  • At 1 year: 3.3% vs. 4.8%
  • At 1-2 years: 0.1% vs. 1.2%
  • At 2-3 years: 0.4% vs. 1.2%

There were no significant differences between the two groups in the MACCE rate among patients with low-risk SYNTAX scores at baseline. CABG was superior to PCI in patients with intermediate and high SYNTAX scores.

Kappetein concluded:

The 3-year SYNTAX results suggest that CABG remains the standard of care for patients with complex disease (intermediate or high SYNTAX Scores); however, PCI may be an acceptable alternative revascularization method to CABG when treating patients with less complex (lower SYNTAX Score) disease.

Note to readers: Rick Lange has started a discussion on this topic in the Interventional Cardiology section of CardioExchange. Click here to join the discussion.

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