For Three-Vessel Disease, but Not Left Main Disease, CABG Is Preferred over PCI

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial

CLINICAL QUESTION

For patients with three-vessel disease or left main disease, is percutaneous coronary intervention (PCI) with a drug-eluting stent noninferior to coronary artery bypass graft (CABG)?

VERDIT

At 10 years, no significant difference existed in all-cause death between PCI using first-generation paclitaxel-eluting stents and CABG. However, CABG provided a significant survival benefit in patients with three-vessel disease, but not in patients with left main coronary artery disease.

 

Study design: Randomized controlled trial (nonblinded) Funding source: Government Allocation: Concealed Setting: Outpatient (any) Reference: SYNTAX trial. Lancet. 2019;394(10206):1325–1334.


Bottom Line
For patients with left main disease, PCI with a drug-eluting stent and CABG had similar all-cause mortality rates at 10 years. For those with three-vessel disease, CABG is associated with lower 10-year mortality (21% vs. 28%; number needed to treat = 14). (Level of Evidence = 1b)

Synopsis
This is the 10-year follow-up to a trial that initially randomized 1,800 patients with three-vessel coronary artery disease or left main disease to receive either PCI with a drug-eluting stent or CABG. Groups were balanced at the beginning of the trial, and analysis was by intention to treat. The average age of participants was 65 years, 25% had diabetes mellitus, 33% had a previous myocardial infarction, and 9% had a previous stroke or transient ischemic attack. Left main disease was present in 40% and three-vessel disease in 60% of the patients. The primary outcome was all-cause mortality, ascertained primarily from national death registries. Median follow-up was 11.2 years. At 10 years, 27% of patients in the PCI group had died compared with 24% in the CABG group (hazard ratio = 1.17; 95% CI, 0.97 to 1.41). Analyzing the period from five years to 10 years separately, the authors again found no significant difference (13% for PCI vs. 12% for CABG). There was a difference between groups based on their initial lesion. In those with three-vessel disease, all-cause mortality was significantly higher in the PCI group (28% vs. 21%; hazard ratio = 1.41; 95% CI, 1.10 to 1.80), whereas there was no difference in mortality for those with left main disease (26% for PCI vs. 28% for CABG). Results were similar for patients with and without diabetes. FULL TEXT

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