March 17th, 2015

CABG vs. PCI for Multivessel CAD: Do Second-Generation Stents Make a Difference

By Howard C. Herrmann, MD

Second-generation stents narrow the gap between coronary artery bypass grafting and percutaneous coronary intervention for nondiabetic patients with multivessel disease, according to findings from two studies published in the New England Journal of Medicine.

The studies provide a wealth of data informing clinicians and patients about the differences between CABG and PCI for multivessel coronary artery disease. PCI may offer early safety benefits for stroke, bleeding, and potentially mortality, but poses a greater need for repeat revascularization. Later mortality is similar with the two procedures, but MI rates may be higher after PCI. Overall, these data suggest few differences, except for patients with diabetes and for those in whom complete revascularization cannot be attained. This gives the edge to the less invasive approach, which most patients tend to prefer.

The study details:

In a noninferiority study, 880 Asian patients with multivessel disease were randomized to CABG or PCI with everolimus-eluting stents (EESs). At 2 years, the primary endpoint (death, MI, or target-vessel revascularization) was similar in the two groups (PCI, 11%; CABG, 8%), although the difference became statistically significant by 5 years (15% vs. 11%), due primarily to more repeat revascularizations and a trend toward more MIs with PCI. The primary endpoint significantly favored CABG among diabetics, but not among nondiabetics.

In the second study, investigators used registry data to compare outcomes in 9000 multivessel disease patients undergoing PCI with EESs and 9000 undergoing CABG. Early 30-day mortality and stroke were superior with PCI. At 3 years, the groups, including a diabetes subgroup, had similar mortality. Subsequent spontaneous MI was about 1% annually more frequent after PCI than after CABG, but only when revascularization was incomplete.

Dr. Herrmann is deputy editor for NEJM Journal Watch Cardiology, from which this story was adapted.

2 Responses to “CABG vs. PCI for Multivessel CAD: Do Second-Generation Stents Make a Difference”

  1. The whole CABG/PCI debate has gone on for too long with randomized trials always showing the same thing and observational studies/registries being all over the place. I hope we don’t waste any more taxpayers money on this question. The evidence is there. Evidence based medicine is about applying the evidence with judgement and finesse.

  2. Still the best treatment for atherosclerotic vascular diasease is prevention. Use of CABG or stents shows a failure of primary prevention. It is time for us to focus on primary prevention, not secondary prevention or palliative care (ie-stents and CABG.)

    Edward C Horwitz DO, FACC, FACP
    Senior Cardiologist MALRAM
    Ichilov Hospital/Tel Aviv Med Center