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CABG Better Than Stenting for Multivessel CAD?

Observational data from New York State suggest yes, but this finding has important caveats.

Several small randomized trials have failed to show a long-term mortality difference between stenting and coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease (e.g., Journal Watch Cardiology May 28 2004). In a new observational study, researchers compared outcomes for patients with 2- or 3-vessel CAD who underwent CABG (37,212) or stenting (22,102) in New York State hospitals from 1997 through 2000. Mean follow-up was 1.9 years in the CABG group and 1.6 years in the stenting group. Older age, LV dysfunction, comorbid conditions, and 3-vessel CAD were significantly more common in the CABG group.

The unadjusted in-hospital mortality rate was significantly higher among CABG patients (1.75%) than among stented patients (0.68%). However, survival rates at 3 years (adjusted for baseline differences between the groups) showed a significant advantage of CABG over stenting. This survival advantage ranged from 1.9% (93.3% vs. 91.4%) in patients with 2-vessel CAD without involvement of the left anterior descending artery (LAD) to 4.9% (89.3% vs. 84.4%) in patients with 3-vessel CAD and proximal LAD involvement. In addition, the rate of repeat revascularization at 3 years was significantly lower in the CABG group than in the stenting group (5% vs. about 35%).

Comment: This large observational study of patients with multivessel CAD documents better survival with CABG than with stenting, thereby contradicting results from several randomized trials that the current authors suggest might have been underpowered. Of course, as an editorialist notes, the observational study is weakened by the fact that treatment choices were left to physicians and by the inability to account for all potentially confounding variables. Nevertheless, the data suggest we should exercise some caution in choosing percutaneous coronary intervention for the highest-risk patients (e.g., those with 3-vessel CAD involving the proximal LAD and LV dysfunction). Additional comparisons will be needed in the era of drug-eluting stents, off-pump CABG, and aggressive risk-factor modification.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology June 17, 2005

Citation(s):

Hannan EL et al. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med 2005 May 26; 352:2174-83.

• Original article (Subscription may be required)
• Medline abstract (Free)

Gersh BJ and Frye RL. Methods of coronary revascularization — Things may not be as they seem. N Engl J Med 2005 May 26; 352:2235-7.

• Original article (Subscription may be required)
• Medline abstract (Free)