Published Online
on August 25, 2008

A more recent version of this article appeared on September 9, 2008

This Article Full Text (PDF) CME: Take the course for this article: Circulation: September 9, 2008, Volume 118, Number 11 All Versions of this Article: 118/11/1146    most recent CIRCULATIONAHA.107.752147v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Daemen, J. Articles by Serruys, P. W. Search for Related Content PubMed PubMed Citation Articles by Daemen, J. Articles by Serruys, P. W. Related Collections Restenosis Other diabetes Catheter-based coronary interventions: stents CV surgery: coronary artery disease Related Article

Submitted on November 13, 2007
Accepted on June 30, 2008

Long-Term Safety and Efficacy of Percutaneous Coronary Intervention With Stenting and Coronary Artery Bypass Surgery for Multivessel Coronary Artery Disease. A Meta-Analysis With 5-Year Patient-Level Data From the ARTS, ERACI-II, MASS-II, and SoS Trials

Joost Daemen MD, Eric Boersma PhD, Marcus Flather MBBS, Jean Booth MSc, Rod Stables MA, DM, FRCP, Alfredo Rodriguez MD, Gaston Rodriguez-Granillo MD, PhD, Whady A. Hueb MD, Pedro A. Lemos MD, PhD, and Patrick W. Serruys MD, PhD^*

From Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands (J.D., E.B., P.W.S.); Clinical Trials and Evaluation Unit, Royal Brompton Hospital, London, UK (M.F., J.B., R.S.); Otamendi Hospital, Buenos Aires, Argentina (A.R., G.R.-G.); and Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil (W.A.H., P.A.L.).

^* To whom correspondence should be addressed. E-mail: p.w.j.c.serruys{at}erasmusmc.nl.

Background—Randomized trials that studied clinical outcomes after percutaneous coronary intervention (PCI) with bare metal stenting versus coronary artery bypass grafting (CABG) are underpowered to properly assess safety end points like death, stroke, and myocardial infarction. Pooling data from randomized controlled trials increases the statistical power and allows better assessment of the treatment effect in high-risk subgroups.

Methods and Results—We performed a pooled analysis of 3051 patients in 4 randomized trials evaluating the relative safety and efficacy of PCI with stenting and CABG at 5 years for the treatment of multivessel coronary artery disease. The primary end point was the composite end point of death, stroke, or myocardial infarction. The secondary end point was the occurrence of major adverse cardiac and cerebrovascular accidents, death, stroke, myocardial infarction, and repeat revascularization. We tested for heterogeneities in treatment effect in patient subgroups. At 5 years, the cumulative incidence of death, myocardial infarction, and stroke was similar in patients randomized to PCI with stenting versus CABG (16.7% versus 16.9%, respectively; hazard ratio, 1.04, 95% confidence interval, 0.86 to 1.27; P=0.69). Repeat revascularization, however, occurred significantly more frequently after PCI than CABG (29.0% versus 7.9%, respectively; hazard ratio, 0.23; 95% confidence interval, 0.18 to 0.29; P<0.001). Major adverse cardiac and cerebrovascular events were significantly higher in the PCI than the CABG group (39.2% versus 23.0%, respectively; hazard ratio, 0.53; 95% confidence interval, 0.45 to 0.61; P<0.001). No heterogeneity of treatment effect was found in the subgroups, including diabetic patients and those presenting with 3-vessel disease.

Conclusions—In this pooled analysis of 4 randomized trials, PCI with stenting was associated with a long-term safety profile similar to that of CABG. However, as a result of persistently lower repeat revascularization rates in the CABG patients, overall major adverse cardiac and cerebrovascular event rates were significantly lower in the CABG group at 5 years.

Key words: bypass • coronary disease • prognosis • stents • surgery

Related Article:

Clinical Summaries
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