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J Am Coll Cardiol, 2003; 41:1293-1304, doi:10.1016/S0735-1097(03)00157-8
© 2003 by the American College of Cardiology Foundation
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CLINICAL STUDY: CORONARY REVASCULARIZATION

A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes

Stuart N. Hoffman, DO*, John A. TenBrook, Jr, MD*, Michael P. Wolf, MD*, Stephen G. Pauker, MD, FACC*{dagger}, Deeb N. Salem, MD, FACC*{dagger} and John B. Wong, MD*,*,1

* Department of Medicine, Division of Clinical Decision Making, Informatics, and Telemedicine, Boston, Massachusetts, USA
{dagger} Division of Cardiology, Tufts-New England Medical Center, Boston, Massachusetts, USA

Manuscript received September 10, 2002; revised manuscript received January 8, 2003, accepted January 16, 2003.

* Reprint requests and correspondence: Dr. John B. Wong, Tufts-New England Medical Center, 750 Washington Street #302, Boston, Massachusetts 02111-1526, USA.
jwong{at}tufts-nemc.org

OBJECTIVES: We performed a meta-analysis of randomized trials comparing coronary artery bypass graft surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) for the treatment of coronary artery disease, incorporating new trials and examining long-term outcomes.

BACKGROUND: Previous meta-analyses of trials comparing CABG with PTCA have reported short- and intermediate-term outcomes, but since then longer term follow-up and newer trials have been published.

METHODS: We performed a meta-analysis of 13 randomized trials on 7,964 patients comparing PTCA with CABG.

RESULTS: We found a 1.9% absolute survival advantage favoring CABG over PTCA for all trials at five years (p < 0.02), but no significant advantage at one, three, or eight years. In subgroup analysis of multivessel disease, CABG provided significant survival advantage at both five and eight years. Patients randomized to PTCA had more repeat revascularizations at all time points (risk difference [RD] 24% to 38%, p < 0.001); with stents, this RD was reduced to 15% at one and three years. Stents also resulted in a significant decrease in nonfatal myocardial infarction at three years when compared with CABG. For diabetic patients, CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years.

CONCLUSIONS: Our results suggest that, when compared with PTCA, CABG is associated with a lower five-year mortality, less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat revascularization by about half.

Abbreviations and Acronyms
  AWESOME
  Angina With Extremely Serious Operative Mortality Evaluation
  CABG
  coronary artery bypass graft surgery
  LAD
  left anterior descending coronary artery
  MI
  myocardial infarction
  NNT
  number needed to treat
  PTCA
  percutaneous transluminal coronary angioplasty
  RD
  risk difference




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