A meta-analysis found no statistically significant difference in 5-year all-cause mortality for percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) in patients with left main coronary artery disease (CAD) and low or intermediate coronary anatomical complexity. The study findings were published in The Lancet.
Investigators from Brigham and Women’s Hospital and Harvard Medical School searched publication databases through August 2021 for randomized controlled trials comparing drug-eluting stent PCI with CABG among patients with left main CAD. An individual patient data meta-analysis was performed using information from SYNTAX (n=705), PRECOMBAT (n=600), NOBLE (n=1184), and EXCEL (n=1905) studies.
Patients had a median age of 66 (IQR, 59-73) years; 76.7% were men; 64.3% resided in Europe; 74.0% were White; SYNTAX score was 25.0 (IQR, 18.0-31.0); 31.4% had left main plus 1 vessel; 31.6% left main plus 2 vessels; 70.1% had dyslipidemia; 67.3% hypertension; 25.1% diabetes; 17.3% had a previous myocardial infarction; and 14.6% previous PCI.
Patients were randomly assigned to receive treatment with PCI (n=2197) or CABG (n=2197). The PCI cohort received a median of 2.0 (IQR, 1.0-3.0) stents with a total length of 42.0 (IQR, 24.0-69.0) mm. Most of the CABG cohort (95.6%) received left internal mammary artery graft with a median of 2.0 (IQR, 2.0-3.0) total conduits.
All-cause mortality at 5 years was 11.2% (95% CI, 9.9%-12.6%) for PCI and 10.2% (95% CI, 9.0%-11.6%) for CABG, indicating no significant difference (hazard ratio [HR], 1.10; 95% CI, 0.91-1.32; P =.33).
Cardiovascular death occurred among 6.2% and 5.9% over 5 years among the PCI and CABG cohorts (HR, 1.07; 95% CI, 0.83-1.37). Non-cardiovascular deaths did not differ between cohorts (HR, 1.16; 95% CI, 0.88-1.54).
Stratified by time, all-cause mortality was lower among PCI recipients (2.7% vs 3.3%) during the first year. Between years 1 and 5, rates were higher among the PCI recipients (8.7% vs 7.2%). The absolute risk difference in cardiovascular deaths by year were -0.1%, 0.1%, 0.3%, 0.7%, and 0.4% at years 1-5, respectively.
Up to year 10, mortality rates did not differ significantly for PCI and CABG (22.4% vs 20.4%; HR, 1.10; 95% CI, 0.93-1.29; P =.25).
PCI was associated with increased repeat revascularization (HR, 1.78; 95% CI, 1.51-2.10; P <.0001) and spontaneous myocardial infarction (HR, 2.35; 95% CI, 1.71-3.23; P <.0001) but decreased risk for procedural myocardial infarction (odds ratio [OR], 0.65; 95% CI, 0.47-0.92; P =.013).
A subgroup analysis did not uncover significant heterogeneity on the basis of age, gender, comorbidities, coronary anatomical complexity, clinical characteristics, or disease extent.
This study may have been limited as these trials were conducted over a long period, during which time stent technology and surgical techniques have evolved.
This meta-analysis found little evidence of differences in five-year mortality among patients who received PCI or CAGB for left main CAD with low or intermediate coronary anatomical complexity.
Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.
Sabatine MS, Bergmark BA, Murphy SA, et al. Percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting in left main coronary artery disease: an individual patient data meta-analysis. Lancet. Published online November 15, 2021. doi:10.1016/S0140-6736(21)02334-5