PCI brings higher risk for MACCE than CABG in triple-vessel CAD
MedWire News: A large Japanese registry study has confirmed the findings of the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) trial, showing that percutaneous coronary intervention (PCI) is associated with a significantly increased risk for serious adverse events compared with coronary artery bypass graft (CABG) surgery in patients with triple-vessel coronary artery disease (TVD).
"CABG would still remain the standard treatment option in patients with triple-vessel coronary artery disease, particularly when their SYNTAX scores are high," said investigator Takeshi Kimura (Graduate School of Medicine, Kyoto University, Japan).
"Use of PCI in patients with high SYNTAX score should be seriously discouraged unless the operative risk is prohibitively high. Selection of revascularization strategies in TVD patients with less complex coronary anatomy deserves further consideration."
The SYNTAX trial was a randomized study showing that for patients with TVD or left main coronary artery disease, the combined endpoint of major adverse cardiac or cerebrovascular events (MACCE) at 1 year was lower with CABG than with PCI.
The trial data also suggested that PCI was associated with a higher risk for a composite endpoint of death, myocardial infarction (MI), and stroke in patients with intermediate or high SYNTAX score, but not in patients with low SYNTAX score, but the study was underpowered to evaluate the significance of this endpoint, prompting the CREDO-KYOTO investigators to test it in a real-world population.
They looked at data from the Coronary REvascularization Demonstrating Outcome Study in Kyoto) CREDO-Kyoto PCI/CABG registry Cohort II on 2981 patients with TVD: 1825 patients who underwent PCI and 1156 who underwent CABG for first coronary revascularization. The primary outcome was a composite of death, MI, and stroke. Secondary outcomes included all-cause mortality, cardiac death, MI, stroke, or any coronary revascularization.
Presenting the findings at the European Society of Cardiology annual congress in Paris, France, Kimura reported that unadjusted analysis echoed SYNTAX findings, showing that PCI was associated with a 3-year incidence of the primary endpoint of 18.3% compared with 15.2% for CABG (p=0.03). All-cause mortality was also higher with PCI than with CABG (11.7% vs 9.3%, p=0.046), as were MI (5.0% vs 2.5%, p=0.002) and any revascularization (42.5% vs 11.2%, p<0.001).
In an analysis stratified by a low, intermediate, or high SYNTAX score, crude analysis showed no difference between PCI or CABG in the primary endpoint among patients with low or intermediate scores, while a higher risk for PCI approached significance among patients with high scores. After adjustment for confounding factors, however, PCI was significantly associated with higher risk even among patients with low SYNTAX scores, Kimura said.
Frans Van der Werf (University Hospital, Leuven, Belgium), the invited discussant, commented that the study confirms the key clinical finding of SYNTAX in a real-world population, as well as the clinical utility of the SYNTAX score. He pointed out, however, that the SYNTAX scored in the CREDO-KYOTO study was applied retrospectively rather than prospectively. In addition, the study was not randomized, and excluded patients with left main coronary artery disease, for reasons that are not clear.
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By Neil Osterweil