If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Difference in spontaneous myocardial infarction and mortality in percutaneous versus surgical revascularization trials: A systematic review and meta-analysis
Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
It has been hypothesized that the survival benefit of coronary artery bypass (CABG) compared with percutaneous interventions (PCI) may be associated with the reduction in spontaneous myocardial infarction (SMI) achieved by surgery. This, however, has not been formally investigated. The present meta-analysis aims to evaluate the association between the difference in SMI and in survival in PCI versus CABG randomized controlled trials (RCTs).
Methods
A systematic search was performed to identify all RCTs comparing PCI with CABG for the treatment of coronary artery disease and reporting SMI outcomes. Generic inverse variance method was used to pool outcomes as natural logarithms of the incident rate ratios across studies. Subgroup analysis and interaction test were used to compare the difference of the primary outcome among trials that did and did not report a significant reduction in SMI- in the patients treated by CABG. Primary outcome was all-cause mortality; secondary outcome was SMI.
Results
Twenty RCTs were included in the meta-analysis. A statistically significant difference in SMI in favor of CABG was found in 7 of the included trials (35%). Overall, PCI was associated with significantly greater all-cause mortality (incident rate ratio, 1.13; 95% confidence interval, 1.01-1.28). At subgroup analysis, a significant difference in survival in favor of CABG was seen only in trials that reported a significant reduction in SMI in the surgical arm (P for interaction 0.02).
Conclusions
In the published PCI versus CABG trials, the reduction in all-cause mortality in the surgical arm is associated with the protective effect of CABG against SMI.
In the published PCI versus CABG trials, the reduction in all-cause mortality in the surgical arm is associated with a protective effect of CABG against SMI.
Our findings support the concept that prevention of SMI may be a mechanism of the CABG survival benefit seen in some revascularization trials.
See Commentary on page 670.
Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) treat coronary artery disease (CAD) using different mechanisms. Whereas PCI dilates the flow-limiting stenosis, CABG creates a new arterial inflow that is generally located several centimeters distal to the target vessel lesions.
This “surgical collateralization” offers protection not only against the flow-limiting lesions but also against the progression of coronary plaques proximal to the graft anastomosis that are noncritical at the time of surgery. As the majority of the acute events in patients with CAD are generated by non–flow-limiting stenoses,
This, however, has never been formally investigated.
We have performed a meta-analysis of the published trials comparing PCI with CABG in patients with CAD. We hypothesized that the survival advantage of CABG was associated with the reduction in spontaneous myocardial infarction (SMI; ie, myocardial infarction occurring >72 hours after the intervention) in the surgical arm.
Methods
A medical librarian performed comprehensive searches to identify all randomized controlled trials (RCTs) comparing PCI versus CABG. Searches were run in November 2019 in the following databases: Ovid MEDLINE (1946 to present); Ovid EMBASE (1974 to present); and The Cochrane Library (Wiley). The full search strategy for Ovid MEDLINE is available in Appendix E1. Institutional review committee approval was not required, as this is a meta-analysis of published data.
Trials were considered for inclusion if they compared PCI with drug-eluting or bare-metal stents with CABG for the treatment of CAD and reported all-cause mortality and SMI data. All articles were reviewed and analyzed for data by 2 independent investigators (C.S., N.B.R.), and disagreements were resolved by a third author (M.G.). The quality of the included studies was assessed using the Cochrane Collaboration's tool for assessing Risk of Bias, Version 2, for randomized trials (Online Data Supplement).
The primary outcome was all-cause mortality. The secondary outcome was SMI.
The generic inverse variance method was used to pool outcomes as natural logarithms of the incident rate ratios (IRRs) across studies to account for potentially different follow-up durations between the groups. Fixed and random effects inverse variance meta-analysis were performed using “metafor” and “meta” packages
in R (version 3.3.3; R Project for Statistical Computing, Vienna, Austria). Publication bias was assessed by funnel plot. Heterogeneity was reported as low (I2 = 0%-25%), moderate (I2 = 26%-50%), or high (I2 >50%). Both random- and fixed-effect models were used; the random effect was considered as the primary model and the fixed effect as a sensitivity analysis.
Subgroup analysis and interaction test were used to evaluate the difference in the primary outcome between trials where a statistically significant difference in SMI was found between groups versus those where no difference was found. Meta-regression was used to test the association between the definition of myocardial infarction used in the different trials and the IRR for SMI.
Results
Searches retrieved 4916 results. Following de-duplication, 4411 citations were screened; a total of 20 RCTs met the inclusion criteria and were included in the meta-analysis (Table 1).
Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial.
Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: 10-year follow-up of a randomized trial.
Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis.
Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial.
Primary stenting versus MIDCAB: preliminary report-comparision of two methods of revascularization in single left anterior descending coronary artery stenosis.
Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending coronary artery.
Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II).
Percutaneous coronary intervention with drug-eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.
Ten-year follow-up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.
Retroinfusion-supported stenting in high-risk patients for percutaneous intervention and bypass surgery: results of the prospective randomized myoprotect I study.
Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non-inferiority NOBLE trial.
10-year follow-up of a prospective randomized trial comparing bare-metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial.
Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.
Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis.
Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial.
Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: 10-year follow-up of a randomized trial.
Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis.
Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial.
Primary stenting versus MIDCAB: preliminary report-comparision of two methods of revascularization in single left anterior descending coronary artery stenosis.
Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending coronary artery.
Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II).
Percutaneous coronary intervention with drug-eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.
Ten-year follow-up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.
Retroinfusion-supported stenting in high-risk patients for percutaneous intervention and bypass surgery: results of the prospective randomized myoprotect I study.
Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non-inferiority NOBLE trial.
10-year follow-up of a prospective randomized trial comparing bare-metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial.
Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.
Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis.
Details for SMI definitions used are reported in Appendix E1. SMI, Spontaneous myocardial infarction; ARTS, Arterial Revascularization Therapies Study; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; BEST, Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease; MI, myocardial infarction; CARDia, Coronary Artery Revascularization in Diabetes; ERACI, Argentine Randomized Trial of Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease; EXCEL, Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; FREEDOM, Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease; LE MANS, Left Main Coronary Artery Stenting; MASS II, Medicine, Angioplasty, or Surgery Study; MT, medical therapy; NOBLE, Nordic–Baltic–British Left Main Revascularisation; PRECOMBAT, PREmier of Randomized Comparison of Sirolimus-Eluting Stent Implantation Versus Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Artery Stenosis; SIMA, Stenting versus Internal Mammary Artery grafting; SYNTAX, Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery.
A total of 12,334 patients were included (PCI: 6190; CABG: 6144). The number of patients in the individual trials ranged from 44 to 1905. Weighted mean follow-up was 3.9 years (range, 0.5-11.4 years). Mean age of the patients ranged from 53.7 to 70.0 years. Prevalence of women ranged from 17.0% to 35.9% (PCI: 16.0%-40.0%, CABG: 15.0%-43.0%). Prevalence of diabetes ranged from 7.0% to 100.0% (PCI: 8.0%-100.0%, CABG: 6.0%-100.0%). Patient characteristics, procedural details, and details of medical therapy are summarized in Table E1, Table E2, Table E3. The Cochrane Collaboration's tool for assessing Risk of Bias Version 2 for the assessment of the quality of the individual studies and of the evidence is reported in Appendix E1. The funnel plot for the assessment of publication bias is reported in Figure E1.
In the main analysis, PCI was associated with a significantly greater all-cause mortality at a weighted mean follow-up of 3.9 years (IRR, 1.13; 95% confidence interval [CI], 1.01-1.28, Figure 2). Seven of the included trials (35%) reported a statistically significant reduction in SMI in the CABG arm. At subgroup analysis, a significant reduction in all-cause mortality with CABG was found only in trials that reported a significant reduction of SMI in the surgical arm (P for interaction .02, Figure 2).
Figure 2Forest plot for all-cause mortality. PCI was associated with significantly greater all-cause mortality compared to CABG. IRR, Incidence rate ratio; CI, confidence interval; SMI, spontaneous myocardial infarction; ARTS, Arterial Revascularization Therapies Study; ERACI, Argentine Randomized Trial of Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease; LE MANS, Left Main Coronary Artery Stenting; PRECOMBAT, PREmier of Randomized Comparison of Sirolimus-Eluting Stent Implantation Versus Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Artery Stenosis; SIMA, Stenting versus Internal Mammary Artery grafting; BEST, Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease; CARDia, Coronary Artery Revascularization in Diabetes; EXCEL, Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; FREEDOM, Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease; MASS II, Medicine, Angioplasty, or Surgery Study; NOBLE, Nordic–Baltic–British Left Main Revascularisation; SYNTAX, Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting.
The definition of myocardial infarction used in the different trials was not associated with the IRR for SMI at meta regression (Protocol definition vs Universal Definition; beta 0.15, standard error 0.21, P = .57, see also Table E4).
Results were consistent using random and fixed effect (Figure 2). Leave-one-out analysis confirmed the robustness of the results (Figure 3). A summary of the findings of the study is presented in Figure 4.
Figure 3Leave-one-out analysis for the primary outcome of all-cause mortality (A, random model; B, fixed model). IRR, Incidence rate ratio; CI, confidence interval; ARTS, Arterial Revascularization Therapies Study; EXCEL, Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; BEST, Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease; CARDia, Coronary Artery Revascularization in Diabetes; MASS II, Medicine, Angioplasty, or Surgery Study; FREEDOM, Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease; SYNTAX, Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery; ERACI, Argentine Randomized Trial of Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease; NOBLE, Nordic–Baltic–British Left Main Revascularisation; LE MANS, Left Main Coronary Artery Stenting; PRECOMBAT, PREmier of Randomized Comparison of Sirolimus-Eluting Stent Implantation Versus Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Artery Stenosis; SIMA, Stenting versus Internal Mammary Artery grafting; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting.
In this meta-analysis of 20 RCTs comparing PCI with CABG, we have found that surgery was associated with lower mortality at a weighted mean follow-up of 3.9 years. The survival benefit in the surgical arm was found only in the trials that reported a significant reduction of SMI in the surgical arm.
Recently, a study level meta-analysis of 14 randomized trials comparing routine revascularization with conservative strategy in patients with stable CAD found that, at a follow-up of 4.5 years, revascularization was not associated with a reduction in the risk of death (relative risk, 0.99; 95% CI, 0.90-1.09).
Routine revascularization versus initial medical therapy for stable ischemic heart disease: a systematic review and meta-analysis of randomized trials.
Of note, among the 14,877 patients in the pooled trials, the vast majority of those in the revascularization arm (71.3%) underwent PCI, whereas only 16.2% received CABG as their first revascularization procedure.
A statistically significant survival advantage for CABG versus PCI in patients with multivessel CAD was shown by Head and colleagues
Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data.
in a pooled a pooled analysis of individual patient data from 11 RCTs (11,518 patients) where all-cause mortality at 5 years was 11.5% after PCI versus 8.9% after CABG (hazard ratio, 1.28; 95% CI, 1.09-1.49; P = .001). Notably, the benefit of CABG versus PCI was maintained regardless of the type of stent used for PCI.
Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial.
Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data.
However, to date no attempt at correlating the SMI and mortality outcomes has been performed.
As opposed to PCI, CABG assures protection of the entire coronary bed distal to the target vessel stenosis by creating a new surgical collateral. It has been hypothesized that protection against the progression of stenoses that were non–flow-limiting at the time of surgery, rather than simple ischemia relief, may be the reason for the survival benefit a CABG, a mechanism described as “surgical collateralization.”
The findings of this analysis are biologically plausible, support the surgical collateralization concept, and suggest that the prevention of SMI may be a mechanism explaining the survival benefit seen with CABG compared with PCI in some trials.
This is particularly important because in recent years there has been growing interest in the use of functional studies (namely, fractional flow reserve) to guide CABG grafting strategy.
Our data and previous studies suggest that the reason for the survival benefit of CABG may be the increased protection against disease progression compared with PCI.
The adoption of a functionally based surgical grafting strategy where only ischemia-producing lesions are bypassed (fractional flow reserve–guided CABG) carries the risk of jeopardizing the protective effect of CABG against non–flow-limiting lesions and should be carefully tested in appropriately designed RCTs before routine adoption.
Our study shares the known limitations of aggregate data meta-analyses. Differences in procedural aspects, postprocedural management, definitions of SMI, and follow-up protocol may have existed between the included trials. Furthermore, not all the published trials comparing PCI and CABG reported SMI data and could be included in the analysis. However, statistical heterogeneity was low in all the analysis; of note, the definition of myocardial infarction used was not associated with the IRR for SMI at metaregression.
In conclusion, our findings support the concept that surgical collateralization may be a mechanism of the CABG survival benefit seen in some revascularization trials.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
(percutaneous coronary intervention∗ or percutaneous coronary revascularization∗ or PCI or percutaneous coronary angioplasty or stent or stents or stenting).tw.
3
Angioplasty, Balloon, Coronary/
4
(coronary balloon angioplasties or coronary balloon angioplasty or transluminal coronary balloon dilation or coronary artery balloon dilation or percutaneous transluminal coronary angioplasty or coronary angioplasty or coronary angioplasties or PTCA).tw.
5
or/1-4
6
Coronary Artery Bypass/
7
(coronary adj2 (bypass or graft)).tw.
8
(CABG or aortocoronary anastomosis or total arterial revascularization or total arterial revascularisation or Multiple arterial revascularization or multiple arterial revascularisation).tw.
9
Coronary Artery Bypass, Off-Pump/
10
Internal Mammary-Coronary Artery Anastomosis/
11
((Right Internal Mammary Artery or RIMA or Coronary Internal Mammary Artery or arteria mammaria interna or arteria thoracica interna or internal thoracic artery or mammary internal artery) and (transplant∗ or graft∗ or anastomosis)).tw.
12
(surgical revascularization or cardiac muscle revascularisation or cardiac muscle revascularization or coronary revascularisation or coronary revascularization or heart muscle revascularisation or heart myocardium revascularisation or heart revascularisation or heart revascularization or internal mammary arterial anastomosis or internal mammary arterial implantation or internal mammary artery anastomosis or internal mammary artery graft or internal mammary artery implant or internal mammary artery implantation or internal mammary-coronary artery anastomosis or myocardial revascularisation or myocardial revascularization or myocardium revascularisation or myocardium revascularization or transmyocardial laser revascularisation or transmyocardial laser revascularization or vineberg operation).tw.
13
or/6-12
14
"randomized controlled trial".pt.
15
(random$ or placebo$ or single blind$ or double blind$ or triple blind$).ti,ab
16
(retraction of publication or retracted publication).pt.
17
or/14-16
18
(animals not humans).sh.
19
((comment or editorial or meta-analysis or practice-guideline or review or letter) not "randomized controlled trial").pt.
20
(random sampl$ or random digit$ or random effect$ or random survey or random regression).ti,ab. not "randomized controlled trial".pt.
21
17 not (18 or 19 or 20)
22
5 and 13
23
22 and 21
Figure E1Funnel plot with trim-and-fill method for the primary outcome for assessment of publication bias.
Randomized comparison of percutaneous coronary intervention with sirolimus–eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis.
Primary stenting versus MIDCAB: preliminary report—comparision of two methods of revascularization in single left anterior descending coronary artery stenosis.
Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending coronary artery.
Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II).
Percutaneous coronary intervention with drug–eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.
Ten–year follow–up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.
Retroinfusion–supported stenting in high–risk patients for percutaneous intervention and bypass surgery: results of the prospective randomized myoprotect I study.
Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non–inferiority NOBLE trial.
10–year follow–up of a prospective randomized trial comparing bare–metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial.
Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow–up of the multicentre randomised controlled SYNTAX trial.
Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis.
Randomized comparison of percutaneous coronary intervention with sirolimus–eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis.
Primary stenting versus MIDCAB: preliminary report—comparision of two methods of revascularization in single left anterior descending coronary artery stenosis.
Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending coronary artery.
Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II).
Percutaneous coronary intervention with drug–eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.
Ten–year follow–up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.
Retroinfusion–supported stenting in high–risk patients for percutaneous intervention and bypass surgery: results of the prospective randomized myoprotect I study.
Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non–inferiority NOBLE trial.
10–year follow–up of a prospective randomized trial comparing bare–metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial.
Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow–up of the multicentre randomised controlled SYNTAX trial.
Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis.
SD, Standard deviation; IQR, interquartile range; BMI, body mass index; DM, diabetes mellitus; CAD, coronary artery disease; HTN, hypertension; HCL, hypercholesterolemia; HLD, hyperlipidemia; PVD, peripheral vascular disease; MI, myocardial infarction; TIA, transient ischemic attack; CHF, chronic heart failure; PCI, percutaneous coronary intervention; CABG, Coronary artery bypass grafting; LVEF, left ventricular ejection fraction; SA, stable angina pectoris; UA, unstable angina; ACS, acute coronary syndrome; ARTS, Arterial Revascularization Therapies Study; BEST, Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease; CARDia, Coronary Artery Revascularization in Diabetes; ERACI, Argentine Randomized Trial of Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease; EXCEL, Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; FREEDOM, Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease; LE MANS, Left Main Coronary Artery Stenting; MASS-II, Medicine, Angioplasty, or Surgery Study; NOBLE, Nordic–Baltic–British Left Main Revascularisation; PRECOMBAT, PREmier of Randomized Comparison of Sirolimus-Eluting Stent Implantation Versus Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Artery Stenosis; SIMA, Stenting versus Internal Mammary Artery grafting; SYNTAX, Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery; NYHA, New York Heart Association.
Randomized comparison of percutaneous coronary intervention with sirolimus–eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis.
Primary stenting versus MIDCAB: preliminary report—comparision of two methods of revascularization in single left anterior descending coronary artery stenosis.
Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending coronary artery.
Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II).
Percutaneous coronary intervention with drug–eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.
Ten–year follow–up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.
Retroinfusion–supported stenting in high–risk patients for percutaneous intervention and bypass surgery: results of the prospective randomized myoprotect I study.
Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non–inferiority NOBLE trial.
10–year follow–up of a prospective randomized trial comparing bare–metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial.
Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow–up of the multicentre randomised controlled SYNTAX trial.
Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis.
Randomized comparison of percutaneous coronary intervention with sirolimus–eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis.
Primary stenting versus MIDCAB: preliminary report—comparision of two methods of revascularization in single left anterior descending coronary artery stenosis.
Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending coronary artery.
Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II).
Percutaneous coronary intervention with drug–eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.
Ten–year follow–up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.
Retroinfusion–supported stenting in high–risk patients for percutaneous intervention and bypass surgery: results of the prospective randomized myoprotect I study.
Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non–inferiority NOBLE trial.
10–year follow–up of a prospective randomized trial comparing bare–metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial.
Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow–up of the multicentre randomised controlled SYNTAX trial.
Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis.
GP, Glycoprotein IIa IIb; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blockers; SD, standard deviation; IQR, interquartile range; CR, complete revascularization; DES, drug-eluting stent; LMCA, left main coronary artery; PCI, percutaneous coronary intervention; ARTS, Arterial Revascularization Therapies Study; CABG, coronary artery bypass grafting; BMS, bare-metal stent; BEST, Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease; CARDia, Coronary Artery Revascularization in Diabetes; ERACI, Argentine Randomized Trial of Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease; EXCEL, Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; FREEDOM, Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease; LE MANS, Left Main Coronary Artery Stenting; MASS-II, Medicine, Angioplasty, or Surgery Study; NOBLE, Nordic–Baltic–British Left Main Revascularisation; PRECOMBAT, PREmier of Randomized Comparison of Sirolimus-Eluting Stent Implantation Versus Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Artery Stenosis; SIMA, Stenting versus Internal Mammary Artery grafting; SYNTAX, Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery; LIMA, left internal mammary artery; BIMA, bilateral internal mammary artery; OPCAB, off-pump coronary artery bypass grafting; SV, saphenous vein.
Randomized comparison of percutaneous coronary intervention with sirolimus–eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis.
PCI: antiplatelet therapy (>100 mg/d, indefinitely); clopidogrel (75 mg/d, ≥12 mo); glycoprotein IIb/IIIa inhibitor use was left to the discretion of the operator.
•
CABG: aspirin (100 mg/d, indefinitely)
•
BOTH: other pharmacologic treatments such as statins, ACE inhibitors, and beta-blockers were recommended based on current practice in both treatment groups.
Primary stenting versus MIDCAB: preliminary report—comparision of two methods of revascularization in single left anterior descending coronary artery stenosis.
Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending coronary artery.
Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II).
Percutaneous coronary intervention with drug–eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.
PCI: acetylsalicylic acid and thienopyridine (clopidogrel or ticlopidine) was initiated at least 2 d before the procedure. Intravenous glycoprotein IIb/IIIa blockers were used at the operator's discretion only in procedures performed in patients with complex coronary lesions and unstable angina. Unfractionated heparin was used in standard doses.
•
CABG: Double antiplatelet treatment (≥12 mo); other pharmacologic treatments (eg, statins, ACE inhibitors, beta-blockers) were recommended based on current practice and were left to the discretion of a supervising physician.
Ten–year follow–up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.
All: optimal medical regimen of titrated nitrates, aspirin, beta-blockers, calcium-channel blockers, ACE inhibitors, or a combination of these drugs unless contraindicated.
•
Lipid-lowering agents, particularly statins, were also prescribed, along with a low-fat diet, on an individual basis.
Retroinfusion–supported stenting in high–risk patients for percutaneous intervention and bypass surgery: results of the prospective randomized myoprotect I study.
Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non–inferiority NOBLE trial.
10–year follow–up of a prospective randomized trial comparing bare–metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial.
Antiplatelet therapy (94% PCI and 96% CABG) Lipid-lowering therapy increased gradually from 24% at 2 y to 89% (88% PCI and 91% CABG) Beta-blockers, ACE inhibitors, and calcium antagonists: more than 50% of the patients without differences between the 2 groups
Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow–up of the multicentre randomised controlled SYNTAX trial.
Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis.
ARTS, Arterial Revascularization Therapies Study; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; BEST, Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease; ACE, angiotensin-converting enzyme; CARDia, Coronary Artery Revascularization in Diabetes; BMS, bare-metal stent; DES, drug-eluting stent; ERACI, Argentine Randomized Trial of Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease; EXCEL, Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; FREEDOM, Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease; LE MANS, Left Main Coronary Artery Stenting; MASS-II, Medicine, Angioplasty, or Surgery Study; HMG-CoA, β-hydroxy β-methylglutaryl-CoA; NOBLE, Nordic–Baltic–British Left Main Revascularisation; PRECOMBAT, PREmier of Randomized Comparison of Sirolimus-Eluting Stent Implantation Versus Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Artery Stenosis; SIMA, Stenting versus Internal Mammary Artery grafting; SYNTAX, Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery.
From: Serruys PW, Unger F, Sousa JE, et al., Arterial Revascularization Therapies Study Group. Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med. 2001;344:1117-24.
MI >48 h after PCI or CABG defined as rise and/or fall of cardiac biomarkers (CK-MB or troponin) >1 times URL + new ECG changes suggesting ischemia, or new pathologic Q waves
From: Thygesen K, Alpert JS, White HD, et al., Joint ESC/ACCF/AHA/WHF task force for the redefinition of myocardial infarction. J Am Coll Cardiol. 2007;50:2173-95
Randomized comparison of percutaneous coronary intervention with sirolimus–eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis.
MI >7 d after PCI or CABG defined as at least 2 of: raised enzymes (CK/CKMB > ×2 URL or Troponin T or I >1), new Q waves on ECG, clinical evidence of ischemic symptoms
Primary stenting versus MIDCAB: preliminary report—comparision of two methods of revascularization in single left anterior descending coronary artery stenosis.
Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending coronary artery.
MI defined as characteristic electrocardiographic findings in combination with elevation of total CK and CK-MB levels. CK levels >2 times the URL and a CK/CK-MB ratio >10% confirmed the diagnosis
Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II).
A Q-wave MI was defined as new pathologic Q-waves, or new LBBB with >3 times CK-MB rise, judged to be present on the basis of a review of all ECGs obtained as part of the study protocol and other ECGs associated with admission
Spontaneous MI defined as the occurrence >72 h after any PCI or CABG of the rise and/or fall of cardiac biomarkers (CK-MB or troponin) >1 times URL PLUS:
•
ECG changes indicative of new ischemia (ST–segment elevation or depression, in the absence of other causes of ST–segment changes such as left ventricular hypertrophy or BBB), or
•
Development of pathological Q waves (≥0.04 s in duration and ≥1 mm in depth) in ≥2 contiguous precordial leads or ≥2 adjacent limb leads) of the ECG, or
•
Angiographically documented graft or native coronary artery occlusion or new severe stenosis with thrombosis and/or diminished epicardial flow, or
•
Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
Following the first 30 d after any revascularization procedure, MI was defined as either a typical increase in the troponin level or a more rapid rise and fall in CK-MB with the presence of one or more of the following factors: ischemic symptoms, development of pathologic Q waves on electrocardiography, changes indicative of ischemia on electrocardiography, the need for repeated coronary-artery intervention, or pathologic findings of an acute myocardial infarction
Percutaneous coronary intervention with drug–eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.
Ten–year follow–up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.
MI defined as the presence of significant new Q waves in at least 2 ECG leads or symptoms compatible with MI associated with CK-MB concentrations >3 times the URL
Retroinfusion–supported stenting in high–risk patients for percutaneous intervention and bypass surgery: results of the prospective randomized myoprotect I study.
Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non–inferiority NOBLE trial.
Non–procedure-related MI defined as a rise in biochemical markers exceeding the 99th percentile including <10% CV with at least one of the following; ischemic symptoms, ECG changes indicative of ischemia (ST-segment elevation or depression), and development of a pathologic Q-wave with no relation to a PCI procedure
MI defined as appearance of new Q waves or an increase in CK–MB greater than the URL, plus ischemic symptoms or signs, if occurring >48 h after the procedure
10–year follow–up of a prospective randomized trial comparing bare–metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial.
Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow–up of the multicentre randomised controlled SYNTAX trial.
Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis.
Thygesen K, Alpert JS, White HD, et al., Joint ESC/ACCF/AHA/WHF task force for the redefinition of myocardial infarction. J Am Coll Cardiol. 2007;50:2173-95
MI, Myocardial infarction; ARTS, Arterial Revascularization Therapies Study; BEST, Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; CK-MB, creatine kinase-myocardial band; URL, upper reference limit; ECG, electrocardiogram; ESC/ACCF/AHA/WHF, European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation; CARDia, Coronary Artery Revascularization in Diabetes; ERACI, Argentine Randomized Trial of Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease; LBBB, left bundle branch block; EXCEL, Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; BBB, bundle branch block; FREEDOM, Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease; LE MANS, Left Main Coronary Artery Stenting; MASS II, Medicine, Angioplasty, or Surgery Study; NOBLE, Nordic–Baltic–British Left Main Revascularisation; CV, coefficient variation; PRECOMBAT, PREmier of Randomized Comparison of Sirolimus-Eluting Stent Implantation Versus Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Artery Stenosis; SIMA, Stenting versus Internal Mammary Artery grafting; SYNTAX, Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery.
Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial.
Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: 10-year follow-up of a randomized trial.
Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis.
Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial.
Primary stenting versus MIDCAB: preliminary report-comparision of two methods of revascularization in single left anterior descending coronary artery stenosis.
Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending coronary artery.
Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II).
Percutaneous coronary intervention with drug-eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.
Ten-year follow-up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.
Retroinfusion-supported stenting in high-risk patients for percutaneous intervention and bypass surgery: results of the prospective randomized myoprotect I study.
Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non-inferiority NOBLE trial.
10-year follow-up of a prospective randomized trial comparing bare-metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial.
Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.
Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis.
Routine revascularization versus initial medical therapy for stable ischemic heart disease: a systematic review and meta-analysis of randomized trials.
Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data.
Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have been compared in numerous randomized control trials (RCT) over 25 years. Both treat coronary artery disease (CAD) to relieve angina and myocardial ischemia but in very different ways. While flow-restricting coronary artery stenosis is locally dilated by PCI, a new inflow of blood supply through a bypass graft is constructed distal to the stenosis in CABG, an effect called “surgical collateralization.” Particularly in severe CAD, that difference is believed to give rise to a difference in protection against subsequent spontaneous myocardial infarction (SMI).
00746-7&id=fx1.jpg){kind=link}
00746-7&id=fx2.jpg){kind=link}
00746-7&id=gr1.jpg){kind=link}
00746-7&id=gr2.jpg){kind=link}
00746-7&id=gr3.jpg){kind=link}
00746-7&id=gr4.jpg){kind=link}
00746-7&id=fx3.jpg){kind=link}