A new study released on Tuesday, March 27 during the final Late-Breaking Clinical Trial session at ACC.12 in Chicago, indicates that coronary artery bypass graft (CABG) surgery appears to carry a higher long-term survival rate than percutaneous coronary intervention (PCI).
The study, “Survival after PCI or CABG in Older Patients with Stable Multivessel Coronary Disease: Results from the ACCF-STS Database Collaboration on the Comparative Effectiveness of Revascularization Strategies” (ASCERT), analyzed health outcomes of 190,000 patients across the U.S. between 2004 and 2008 using data from the ACC’s CathPCI Registry®, The Society of Thoracic Surgeons CABG database and the Medicare claims database. It compared the results of CABG to PCI and found that patients who underwent PCI had a higher death rate in the first four years after treatment than those who had opted for CABG (20.8 percent and 16.41 percent, respectively).
“Our study is the most general one ever done because it uses data from across the whole country. It is also much larger than any other study,” said William S. Weintraub, MD, FACC, chair of cardiology at Christiana Care Health System and the study’s lead investigator. “Combining data from several large databases, we found that survival was better with coronary surgery than percutaneous coronary intervention.”
While some previous studies have suggested the two treatments have similar long-term outcomes, others have also shown better outcomes with CABG. Updated ACCF/AHA guidelines for both PCI and CABG released last November state that PCI to improve patient survival is a reasonable alternative to CABG in stable patients with left main coronary artery disease who have a low risk of PCI complications and an increased risk of adverse surgical outcomes. The guideline also confirms the superiority of CABG compared to medical therapy and to PCI for most patients with 3-vessel disease.
However, the guidelines also recommend using a “heart team” approach to determine which procedure should be used. This approach means that the interventional cardiologist and the cardiac surgeon review the patient’s condition, determine the pros and cons of each treatment option, and then present this information to the patient, allowing him or her to make a more informed decision.
“Results from studies like Ascert should be shared with patients as part of the decision-making process,” said ACC’s Senior Vice President for Science and Quality William Oetgen, MD, FACC. He noted that to date patients and doctors tend to choose the less-invasive PCI when both treatments are an option.
Weintraub also cautioned that the results do not mean bypass surgery is best for every patient. He noted that a major limitation of observational studies, such as this one, is that the groups may not have the same level of risk, and so it is possible that the worse outcomes in the PCI patients were related to these patients being sicker overall “It does push the needle toward coronary surgery, but not overwhelmingly so,” said Weintraub. “When we’re recommending coronary surgery to patients, even though it is a bigger intervention than PCI, we can now have a little more confidence that the decision is a good one.”