• CABG vs. stents

    The results of SYNTAX are clear. Overall, at 5 years CABG [coronary artery bybass grafting] significantly reduced major adverse cardiac and cerebrovascular events (MACCE) at 26·9% in the CABG group versus 37·3% in the PCI [percutaneous coronary intervention] group (p<0·0001), including cardiac death (5·3% vs 9·0%; p=0·003), myocardial infarction (3·8% vs 9·7%; p<0·0001), and repeat revascularisation (13·7% vs 25·9%; p<0·0001). The investigators noted no significant difference in all-cause death (11·4% vs 13·9%; p=0·10) or stroke (3·7% vs 2·4%: p=0·09). [...]

    Patients with lower and intermediate severity coronary artery disease had similar survival with PCI and CABG, whereas in the group with severe coronary artery disease CABG resulted in significantly lower mortality (11·4% with CABG vs 19·2% with PCI: p=0·005), myocardial infarction (3·9% vs 10·1%: p=0·004), and repeat revascularisation (12·1% vs 30·9%: p<0·0001). CABG also seemed to have greater benefit on MACCE in patients with isolated three-vessel disease (24·2% vs 37·5%: p<0·0001) than with left main disease (31·0% vs 36·9%: p=0·12). [...]

    In the 25% of patients with diabetes in the SYNTAX trial, occurrence of MACCE was also significantly higher with PCI (46·5%) versus CABG (29·0%; p=0·0002).

    The rest of David Taggart’s Lancet commentary is here, but gated. The SYNTAX trial report appears in the same issue.

    With results like these, I wonder if PCI is ever warranted. Taggart notes that “interventional cardiologists will argue that they could potentially achieve better results with newer generation stents.” It’s possible. It’s also true that interventional cardiologists make their living from PCI, a not insignificant conflict. Another clue is found in the exclusions from randomization into SYNTAX.

    [A] further 1275 patients (around 40% of the total) were deemed ineligible for randomisation because their coronary artery disease was either thought to be too complex for PCI (1077 who underwent CABG) or too high risk for CABG (198 who underwent PCI).

    Is there broad agreement that some patients are at too high risk for CABG and also benefit from PCI? If so, then that’s a clear subpopulation for which PCI makes sense. Are there others? I don’t want to be overly harsh on PCI. I don’t want to be unjustifiably lenient either.


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    • PCI is overused. It is a vital intervention for acute STEMI (the classic heart attack). For people with chronic heart-related chest pain (stable angina), SYNTAX, FREEDOM, and other have shown that PCI helps chest pain but does not prevent heart attacks or decrease mortality. In some patients, CABG does.

      People have not learned this lesson. In 2011 Chan et al published in JAMA that 11.6% of nonacute PCI was inappropriate and 38% were of uncertain appropriateness, using a very lenient definition of appropriate.

      Furthermore, patients don’t know this. In Annals in 2010, Rothberg et al showed that 88% of patients receiving PCI thought it would reduce their heart attack risk! And “of cardiologists who identified no benefit of PCI in 2 scenarios, 43% indicated that they would still proceed with PCI in these cases.” Ack!

      • J. — Regarding the 2011 JAMA study by Chan et al, you should read my interview with Dr. Chan (http://www.ptca.org/stentcenter/paul_chan_interview.html) in which he discusses how the terms “inappropriate” and “uncertain” can be misinterpreted. He states, “You can see the press potentially saying, ’50% of elective angioplasties are not appropriate….’ And that IS a misinterpretation!” BTW, the Guidelines committee has since changed the names of these categories to clarify their meaning. See my blog (just Google, “A Stent By Any Other Name Now Has Other Names!”) abou this. For example, “Uncertain” is now called “May Be Appropriate.”

    • two quick cents:
      Isn’t SYNTAX a comparsion of PCI vs CABG in patients with 3V disease or LM disease? So for patients with less severe or less diffuse disease may still be good candidates for PCI. I think this is kind of alluded to in the statement “patients with lower and intermediate CAD had similar survival with PCI and CABG…”
      As to the question of a patient population that are too high risk for CABG, My guess is that there are some patients judged very poor operative candidates (thinking primarily about concurrent severe pulmonary disease), for whom short operative duration and lack of general anesthesia make more sense. I took a quick gander and couldn’t find specific evidence for this idea, but that would be my first thought.

    • Massively, morbidly obese and really awful pulmonary disease patients with single vessel disease might be candidates for PCI. When you look at how sick the TAVAR patients are, it is not clear that anyone is really too sick for CABG from a cardiac POV. Also, there is a bit higher stroke rate for CABG with the Freedom trial. Listened to an interview with an author of the Freedom trial. He pointed out that cardiologists often have a “I’m here already” approach to the issue. Will probably take them a while to give that up. At least with the Freedom trial, I think they are largely past the point where they can make claims about new stents coming out.


    • —-It’s also true that interventional cardiologists make their living from PCI, a not insignificant conflict—-

      Surgeons also ” make their living ” from surgery. In the USA surgeons make on average $ 4500 + per surgery in physician fee compared to less than $ 1000 for stent and more than one stent paid even less if at all.