2393CABG confers long-term survival benefit over PCI with second generation stents in real-world patients with multi-vessel coronary artery disease: a propensity matched study of 2698 patients

Abstract

Background: Over the years several randomised controlled trials and metaanalyses have shown potential survival benefit in stable patients with complex multi‐vessel disease (MVD) treated with coronary artery bypass (CABG) versus percutaneous coronary intervention (PCI) using first generation stents. There is conflicting evidence, however, with regards to optimal revascularization in patients with left main stem (LMS) disease whereas data on contemporary revascularization strategies in real world, predominantly acute coronary syndrome (ACS), MVD patients are lacking. Purpose: We sought to compare the long term all‐cause mortality of all‐comer, real‐world patients with MVD including LMS, treated with PCI with second generation drug eluting stents (DES) versus CABG. Methods: Among 6383 all‐comer MVD patients, 1349 patients treated with CABG and 1349 that underwent PCI using second generation DES had similar propensity scores and were included in the analysis. In‐hospital major adverse cardiac events (MACE) as well as 5‐year Kaplan Meier estimated survival rates, were compared. Cox regression was used to adjust for any residual confounding variables. Subgroup analyses were performed according to coronary artery disease pattern (LMS and/or epicardial vessel involvement). Results: Mean age (65.8±10.4 vs. 65.4±12.1, p=0.221) and female gender (20.1\% vs 18.8\%, p=0.381) were similar in CABG and PCI groups respectively. Only 37.9\% of patients treated with CABG and 40.2\% of patients treated with PCI (p=0.221) had stable angina. Cardiogenic shock on admission (2\% vs. 2.1\%, p=0.787), history of myocardial infarction (29.8\% vs. 32\%, p=0.211), previous PCI (25.6\% vs. 24.6\%, p=0.524) previous CABG (6.3\% vs. 8.2\%, p=0.063) and diabetes (25.1\% vs. 24.7\%, 0.789) did not exhibit significant differences between the two groups (CABG vs. PCI respectively). In hospital CVA was significantly higher amongst CABG patients (1.3\% vs. 0.1\%, p{\textless}0.001) whereas in‐hospital re‐intervention, mortality and overall MACE were similar between the two groups. At mean follow up of 3.3 years a significantly higher adjusted hazards ratio (HR) for all cause mortality amongst patients undergoing PCI was observed; HR 1.69, 95\% CI 1.29 to 2.20, p{\textless}0.001. The estimated 5‐year survival was significantly higher amongst patients undergoing CABG (87.3\% vs. 78.5\%, p{\textless}0.001). In patients with LMS and 2VD (HR 4.1 95\% CI 1.97 to 8.54, p{\textless}0.001) and those with LMS and 3VD (HR 3.26, 95\% CI 1.27 to 8.33, p=0.014) an even greater long‐term survival advantage was observed with CABG (Figure). Conclusions: In this contemporary propensity matched cohort of real‐world patients with MVD, CABG confers a significant long‐term survival benefit over PCI with second‐ generation DES. Further more inclusive randomized controlled trials are required to confirm the findings of the current study. (Figure Presented) .