CABG May Be More Effective Than Drug-Eluting Stent in Significant CAD

Coronary artery bypass grafting (CABG) may be superior to implantation of a drug-eluting stent (DES) in patients with mildly to moderately reduced ejection fraction (EF) and significant coronary artery disease (CAD), according to a study published in ESC Heart Failure.

The retrospective, observational study compared long-term outcomes in patients with mild to moderate ischemic heart failure (left ventricular EF 35%-50%) who underwent percutaneous coronary intervention (PCI) with DES or CABG at a hospital in Tianjin, China, from January 2016 to December 2017.

The primary outcome was all-cause death, and secondary outcomes included cardiac death, recurrent myocardial infarction (MI), stroke, and any coronary revascularization with PCI or CABG during follow-up.

A total of 2,050 patients were included in the final analysis. The DES group had 1,330 patients (mean age, 64.1±10.0 years; 74% men) and the CABG group had 720 patients (mean age, 63.3±8.3 years; 76.4% men).

Propensity score matching was conducted for the full cohort, which resulted in 601 matched pairs. The C-statistic for the propensity score model was 0.781, which indicated good discrimination, according to the researchers. The median follow-up was 45 months (IQR, 40-54 months).

Significant differences were observed in all-cause death between the 2 groups. There were 77 patient deaths in the PCI group and 27 in the CABG group (DES vs CABG: 5.8% vs 3.8%; adjusted hazard ratio [HR], 1.525; 95% CI, 0.984-2.364; P =.045).

In the matched-pair patients, all-cause death occurred in 35 participants in the DES group and 16 in the CABG group (DES vs CABG: 5.8% vs 2.7%; adjusted HR, 2.278; 95% CI, 1.261-4.116; P =.006).

No differences were observed regarding rates of cardiac death (DES vs CABG: 4.8% vs 3.0%; adjusted HR, 1.648; 95% CI, 0.915-2.968; P =.096), recurrent MI (DES vs CABG: 4.0% vs 2.8%; adjusted HR, 1.458; 95% CI, 0.783-2.715; P =.234), and stroke (DES vs CABG: 6.8% vs 5.2%; adjusted HR, 1.394; 95% CI, 0.874-2.222; P =.163). The repeat revascularization rate was significantly increased in the PCI group (DES vs CABG: 12.1% vs 6.0%; adjusted HR, 2.162; 95% CI, 1.450-3.224; P =.000).

Study limitations include that the retrospective, observational design, and treatment selection were not based on randomized assignment. In addition, the revascularization strategy selection was determined by anatomic factors without functional guidance, and the small sample size limits the generalizability of the findings.

“Collectively, our results suggest that PCI with DES implantation may be inferior to CABG in mild to moderate ischemic heart failure,” wrote the researchers. “However, it should be emphasized that this finding is for patients with significant CAD (3-main vessel disease). We still do not know whether PCI could be an alternative to CABG in patients with 1- or 2-vessel disease.”

Reference

Wang K, Wang L, Cong H, et al. A comparison of drug-eluting stent and coronary artery bypass grafting in mildly to moderately ischemic heart failure. ESC Heart Fail. Published online February 22, 2022. doi: 10.1002/ehf2.13852