TY - JOUR
T1 - Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease
T2 - Final five-year follow-up of the SYNTAX trial
AU - Head, Stuart J.
AU - Davierwala, Piroze M.
AU - Serruys, Patrick W.
AU - Redwood, Simon R.
AU - Colombo, Antonio
AU - Mack, Michael J.
AU - Morice, Marie Claude
AU - Holmes, David R.
AU - Feldman, Ted E.
AU - Stahle, Elisabeth
AU - Underwood, Paul
AU - Dawkins, Keith D.
AU - Kappetein, A. Pieter
AU - Mohr, Friedrich W.
PY - 2014/10/21
Y1 - 2014/10/21
N2 - Aims Coronary artery bypass grafting (CABG) has been considered the standard of care for patients with three-vessel disease (3VD), but long-term comparative results fromrandomized trials ofCABGvs. percutaneous coronary intervention (PCI) using drug-eluting stents (DES) remain limited. Methods and results Patients with de novo 3VD or left main disease were randomly assigned to PCI with the paclitaxel-eluting first-generation stent or CABG in the SYNTAX trial. This pre-specified analysis presents the 5-year outcomes of patients with 3VD (n = 1095). The rate of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in patients with PCI compared with CABG (37.5 vs. 24.2%, respectively; P < 0.001). Percutaneous coronary intervention as opposed to CABG resulted in significantly higher rates of the composite of death/stroke/myocardial infarction (MI) (22.0 vs. 14.0%, respectively; P < 0.001), all-cause death (14.6 vs. 9.2%, respectively; P = 0.006), MI (9.2 vs. 4.0%, respectively; P = 0.001), and repeat revascularization (25.4 vs. 12.6%, respectively; P < 0.001); however, stroke was similar between groups at 5 years (3.0 vs. 3.5%, respectively; P = 0.66). Results were dependent on lesion complexity (P for interaction = 0.12); in patients with a low (0.22) SYNTAX score, PCI vs. CABG resulted in similar rates of MACCE (33.3% vs. 26.8%, respectively; P = 0.21) but significantly more repeat revascularization (25.4% vs. 12.6%, respectively; P = 0.038), while in intermediate (23.32) or high (.33) SYNTAXscore terciles,CABGdemonstrated clear superiority in terms ofMACCE, death, MI, and repeat revascularization. Differences inMACCE between PCI and CABGwere larger in diabetics [hazard ratio (HR) = 2.30] than non-diabetics (HR = 1.51), although the P for interaction failed to reach significance for MACCE (P for interaction = 0.095) or any of the other endpoints. Conclusion Five-year results of patients with3VD treated withCABGor PCI using the first-generation paclitaxel-eluting DES suggest that CABG should remain the standard of care as it resulted in significantly lower rates of death, MI, and repeat revascularization, while stroke rates were similar. For patients with low SYNTAX scores, PCI is an acceptable revascularization strategy, although at a price of significantly higher rates of repeat revascularization. Clinical trial registration NCT00114972.
AB - Aims Coronary artery bypass grafting (CABG) has been considered the standard of care for patients with three-vessel disease (3VD), but long-term comparative results fromrandomized trials ofCABGvs. percutaneous coronary intervention (PCI) using drug-eluting stents (DES) remain limited. Methods and results Patients with de novo 3VD or left main disease were randomly assigned to PCI with the paclitaxel-eluting first-generation stent or CABG in the SYNTAX trial. This pre-specified analysis presents the 5-year outcomes of patients with 3VD (n = 1095). The rate of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in patients with PCI compared with CABG (37.5 vs. 24.2%, respectively; P < 0.001). Percutaneous coronary intervention as opposed to CABG resulted in significantly higher rates of the composite of death/stroke/myocardial infarction (MI) (22.0 vs. 14.0%, respectively; P < 0.001), all-cause death (14.6 vs. 9.2%, respectively; P = 0.006), MI (9.2 vs. 4.0%, respectively; P = 0.001), and repeat revascularization (25.4 vs. 12.6%, respectively; P < 0.001); however, stroke was similar between groups at 5 years (3.0 vs. 3.5%, respectively; P = 0.66). Results were dependent on lesion complexity (P for interaction = 0.12); in patients with a low (0.22) SYNTAX score, PCI vs. CABG resulted in similar rates of MACCE (33.3% vs. 26.8%, respectively; P = 0.21) but significantly more repeat revascularization (25.4% vs. 12.6%, respectively; P = 0.038), while in intermediate (23.32) or high (.33) SYNTAXscore terciles,CABGdemonstrated clear superiority in terms ofMACCE, death, MI, and repeat revascularization. Differences inMACCE between PCI and CABGwere larger in diabetics [hazard ratio (HR) = 2.30] than non-diabetics (HR = 1.51), although the P for interaction failed to reach significance for MACCE (P for interaction = 0.095) or any of the other endpoints. Conclusion Five-year results of patients with3VD treated withCABGor PCI using the first-generation paclitaxel-eluting DES suggest that CABG should remain the standard of care as it resulted in significantly lower rates of death, MI, and repeat revascularization, while stroke rates were similar. For patients with low SYNTAX scores, PCI is an acceptable revascularization strategy, although at a price of significantly higher rates of repeat revascularization. Clinical trial registration NCT00114972.
KW - Coronary artery bypass grafting
KW - Diabetes
KW - Incomplete revascularization
KW - Percutaneous coronary intervention
KW - Randomized trial
KW - SYNTAX
KW - Three-vessel disease
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U2 - 10.1093/eurheartj/ehu213
DO - 10.1093/eurheartj/ehu213
M3 - Article
C2 - 24849105
AN - SCOPUS:84926016945
SN - 0195-668X
VL - 35
SP - 2821
EP - 2830
JO - European Heart Journal
JF - European Heart Journal
IS - 40
ER -