Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final five-year follow-up of the SYNTAX trial.
OBJECTIVE
Coronary artery bypass grafting (CABG) has been considered the standard of care for patients with three-vessel disease (3VD), but long-term comparative results from randomized trials of CABG vs. percutaneous coronary intervention (PCI) using drug-eluting stents (DES) remain limited.


RESULTS
Patients with de novo 3VD or left main disease were randomly assigned to PCI with the paclitaxel-eluting first-generation stent or CABG in the SYNTAX trial. This pre-specified analysis presents the 5-year outcomes of patients with 3VD (n = 1095). The rate of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in patients with PCI compared with CABG (37.5 vs. 24.2%, respectively; P < 0.001). Percutaneous coronary intervention as opposed to CABG resulted in significantly higher rates of the composite of death/stroke/myocardial infarction (MI) (22.0 vs. 14.0%, respectively; P < 0.001), all-cause death (14.6 vs. 9.2%, respectively; P = 0.006), MI (9.2 vs. 4.0%, respectively; P = 0.001), and repeat revascularization (25.4 vs. 12.6%, respectively; P < 0.001); however, stroke was similar between groups at 5 years (3.0 vs. 3.5%, respectively; P = 0.66). Results were dependent on lesion complexity (P for interaction = 0.12); in patients with a low (0-22) SYNTAX score, PCI vs. CABG resulted in similar rates of MACCE (33.3% vs. 26.8%, respectively; P = 0.21) but significantly more repeat revascularization (25.4% vs. 12.6%, respectively; P = 0.038), while in intermediate (23-32) or high (≥ 33) SYNTAX score terciles, CABG demonstrated clear superiority in terms of MACCE, death, MI, and repeat revascularization. Differences in MACCE between PCI and CABG were larger in diabetics [hazard ratio (HR) = 2.30] than non-diabetics (HR = 1.51), although the P for interaction failed to reach significance for MACCE (P for interaction = 0.095) or any of the other endpoints.


CONCLUSIONS
Five-year results of patients with 3VD treated with CABG or PCI using the first-generation paclitaxel-eluting DES suggest that CABG should remain the standard of care as it resulted in significantly lower rates of death, MI, and repeat revascularization, while stroke rates were similar. For patients with low SYNTAX scores, PCI is an acceptable revascularization strategy, although at a price of significantly higher rates of repeat revascularization.


BACKGROUND
NCT00114972.
Erasmus University Medical Center, Rotterdam, The Netherlands.
Stuart J
SJ
Head
Herzzentrum Universität Leipzig, Strumpelstrasse 39, Leipzig 4289, Germany.
Piroze M
PM
Davierwala
Erasmus University Medical Center, Rotterdam, The Netherlands.
Patrick W
PW
Serruys
Guy's and St. Thomas' Hospital, London, UK.
Simon R
SR
Redwood
San Raffaele Scientific Institute, Milan, Italy.
Antonio
A
Colombo
Medical City Hospital, Dallas, TX, USA.
Michael J
MJ
Mack
Institut Hospitalier Jacques Cartier, Générale de santé, Massy, France.
Marie-Claude
MC
Morice
May Clinic Rochester, Rochester, MN, USA.
David R
DR
Holmes
Evanston Hospital, Evanston, IL, USA.
Ted E
TE
Feldman
University Hospital Uppsala, Uppsala, Sweden.
Elisabeth
E
Ståhle
Boston Scientific Corporation, Natick, MA, USA.
Paul
P
Underwood
Boston Scientific Corporation, Natick, MA, USA.
Keith D
KD
Dawkins
Erasmus University Medical Center, Rotterdam, The Netherlands.
A Pieter
AP
Kappetein
Herzzentrum Universität Leipzig, Strumpelstrasse 39, Leipzig 4289, Germany mohrf@medizin.uni-leipzig.de.
Friedrich W
FW
Mohr
D001026:Coronary Artery Bypass / Q000379:methods*; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery*; D003925:Diabetic Angiopathies / Q000188:drug therapy / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000379:methods / Q000401:mortality; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D011446:Prospective Studies; D020521:Stroke / Q000209:etiology / Q000401:mortality; D016896:Treatment Outcome
Coronary artery bypass grafting; Diabetes; Incomplete revascularization; Percutaneous coronary intervention; Randomized trial; SYNTAX; Three-vessel disease