Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials.
BACKGROUND
Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are alternative treatments for multivessel coronary disease. Although the procedures have been compared in several randomised trials, their long-term effects on mortality in key clinical subgroups are uncertain. We undertook a collaborative analysis of data from randomised trials to assess whether the effects of the procedures on mortality are modified by patient characteristics.


METHODS
We pooled individual patient data from ten randomised trials to compare the effectiveness of CABG with PCI according to patients' baseline clinical characteristics. We used stratified, random effects Cox proportional hazards models to test the effect on all-cause mortality of randomised treatment assignment and its interaction with clinical characteristics. All analyses were by intention to treat.


RESULTS
Ten participating trials provided data on 7812 patients. PCI was done with balloon angioplasty in six trials and with bare-metal stents in four trials. Over a median follow-up of 5.9 years (IQR 5.0-10.0), 575 (15%) of 3889 patients assigned to CABG died compared with 628 (16%) of 3923 patients assigned to PCI (hazard ratio [HR] 0.91, 95% CI 0.82-1.02; p=0.12). In patients with diabetes (CABG, n=615; PCI, n=618), mortality was substantially lower in the CABG group than in the PCI group (HR 0.70, 0.56-0.87); however, mortality was similar between groups in patients without diabetes (HR 0.98, 0.86-1.12; p=0.014 for interaction). Patient age modified the effect of treatment on mortality, with hazard ratios of 1.25 (0.94-1.66) in patients younger than 55 years, 0.90 (0.75-1.09) in patients aged 55-64 years, and 0.82 (0.70-0.97) in patients 65 years and older (p=0.002 for interaction). Treatment effect was not modified by the number of diseased vessels or other baseline characteristics.


CONCLUSIONS
Long-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes. CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups.
Hlatky
Mark A
MA
Stanford University School of Medicine, Stanford, CA, USA.
Boothroyd
Derek B
DB
Bravata
Dena M
DM
Boersma
Eric
E
Booth
Jean
J
Brooks
Maria M
MM
Carrié
Didier
D
Clayton
Tim C
TC
Danchin
Nicolas
N
Flather
Marcus
M
Hamm
Christian W
CW
Hueb
Whady A
WA
Kähler
Jan
J
Kelsey
Sheryl F
SF
King
Spencer B
SB
Kosinski
Andrzej S
AS
Lopes
Neuza
N
McDonald
Kathryn M
KM
Rodriguez
Alfredo
A
Serruys
Patrick
P
Sigwart
Ulrich
U
Stables
Rodney H
RH
Owens
Douglas K
DK
Pocock
Stuart J
SJ
D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D002423:Cause of Death; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000150:complications / Q000401:mortality / Q000628:therapy*; D048909:Diabetes Complications / Q000150:complications; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D016016:Proportional Hazards Models; D016032:Randomized Controlled Trials as Topic; D012107:Research Design; D012307:Risk Factors; D016896:Treatment Outcome