Revascularization in Patients with Multivessel Coronary Artery Disease and Severe Left Ventricular Systolic Dysfunction: Everolimus Eluting Stents vs. Coronary Artery Bypass Graft Surgery
Background—Guidelines recommend coronary artery bypass graft surgery (CABG) over percutaneous coronary intervention (PCI) for multivessel disease and severe left ventricular (LV) systolic dysfunction. However, CABG has not been compared with PCI in such patients in randomized trials.
Methods and Results—Patients with multivessel disease and severe LV systolic dysfunction (ejection fraction ≤35%) who underwent either PCI with everolimus-eluting stent (EES) or CABG were selected from the New York State registries. The primary outcome was long-term all-cause death. Secondary outcomes were individual outcomes of MI, stroke and repeat revascularization. Among the 4,616 patients who fulfilled our inclusion criteria (1,351 EES and 3,265 CABG), propensity score matching identified 2,126 patients with similar propensity scores. At short-term, PCI was associated with a lower risk of stroke [HR=0.05; 95% CI 0.01-0.39; P=0.004] when compared with CABG. At long-term follow-up (median-2.9 years), PCI was associated with a similar risk of death (HR=1.01; 95% CI 0.81-1.28; P=0.91), a higher risk of MI (HR=2.16; 95% CI 1.42-3.28; P=0.0003), a lower risk of stroke (HR=0.57; 95% CI 0.33-0.97; P=0.04) and a higher risk of repeat revascularization (HR=2.54; 95% CI 1.88-3.44; P<0.0001). The test for interaction was significant (P=0.002) for completeness of revascularization, such that in patients where complete revascularization was achieved with PCI, there was no difference in MI between PCI and CABG.
Conclusions—Among patients with multivessel disease and severe LV systolic dysfunction, PCI with EES had comparable long-term survival when compared with CABG. PCI was associated with higher risk of MI (in those with incomplete revascularization) and repeat revascularization, and CABG was associated with higher risk of stroke.
- everolimus eluting
- drug-eluting stent
- left ventricular systolic function
- percutaneous coronary intervention
- coronary artery bypass graft surgery
- Received December 23, 2015.
- Revision received February 26, 2016.
- Accepted March 28, 2016.