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* ,
Deeb N. Salem, MD, FACC* and
John B. Wong, MD*,*,1
* Department of Medicine, Division of Clinical Decision Making, Informatics, and Telemedicine, Boston, Massachusetts, USA
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.
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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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Current percutaneous coronary intervention and coronary artery bypass grafting practices for three-vessel and left main coronary artery disease. Insights from the SYNTAX run-in phase.
Eur. J. Cardiothorac. Surg.,
April 1, 2006;
29(4):
486 - 491.
[Abstract]
[Full Text]
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M. Hordijk-Trion, M. Lenzen, W. Wijns, P. de Jaegere, M. L. Simoons, W. J.M. Scholte op Reimer, M. E. Bertrand, N. Mercado, E. Boersma, and on behalf of the EHS-CR Investigators
Patients enrolled in coronary intervention trials are not representative of patients in clinical practice: results from the Euro Heart Survey on Coronary Revascularization
Eur. Heart J.,
March 2, 2006;
27(6):
671 - 678.
[Abstract]
[Full Text]
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S. G. Raja
Drug-Eluting Stents and the Future of Coronary Artery Bypass Surgery: Facts and Fiction
Ann. Thorac. Surg.,
March 1, 2006;
81(3):
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[Abstract]
[Full Text]
[PDF]
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R. Seabra-Gomes
Percutaneous coronary interventions with drug eluting stents for diabetic patients.
Heart,
March 1, 2006;
92(3):
410 - 419.
[Full Text]
[PDF]
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M. E. Williams
Coronary Revascularization in Diabetic Chronic Kidney Disease/End-Stage Renal Disease: A Nephrologist's Perspective
Clin. J. Am. Soc. Nephrol.,
March 1, 2006;
1(2):
209 - 220.
[Full Text]
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S. B. King III, G. Dangas, J. W. Moses, S. B. King III, G. Dangas, and J. W. Moses
Surgery Is Preferred for the Diabetic With Multivessel Disease
Circulation,
September 6, 2005;
112(10):
1500 - 1515.
[Full Text]
[PDF]
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M. Zimarino, A. M. Calafiore, and R. De Caterina
Complete myocardial revascularization: between myth and reality
Eur. Heart J.,
September 2, 2005;
26(18):
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[Abstract]
[Full Text]
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D. J. Malenka, B. J. Leavitt, M. J. Hearne, J. F. Robb, Y. R. Baribeau, T. J. Ryan, R. E. Helm, M. A. Kellett, H. L. Dauerman, L. J. Dacey, et al.
Comparing Long-Term Survival of Patients With Multivessel Coronary Disease After CABG or PCI: Analysis of BARI-Like Patients in Northern New England
Circulation,
August 30, 2005;
112(9_suppl):
I-371 - I-376.
[Abstract]
[Full Text]
[PDF]
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P. W. Serruys, A. T.L. Ong, L. A. van Herwerden, J. E. Sousa, A. Jatene, J. J.R.M. Bonnier, J. P.M.A. Schonberger, N. Buller, R. Bonser, C. Disco, et al.
Five-Year Outcomes After Coronary Stenting Versus Bypass Surgery for the Treatment of Multivessel Disease: The Final Analysis of the Arterial Revascularization Therapies Study (ARTS) Randomized Trial
J. Am. Coll. Cardiol.,
August 16, 2005;
46(4):
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[Abstract]
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R. M. Califf
Stenting or Surgery: An Opportunity to Do it Right
J. Am. Coll. Cardiol.,
August 16, 2005;
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N. Mercado, W. Wijns, P. W. Serruys, U. Sigwart, M. D. Flather, R. H. Stables, W. W. O'Neill, A. Rodriguez, P. A. Lemos, W. A. Hueb, et al.
One-year outcomes of coronary artery bypass graft surgery versus percutaneous coronary intervention with multiple stenting for multisystem disease: A meta-analysis of individual patient data from randomized clinical trials
J. Thorac. Cardiovasc. Surg.,
August 1, 2005;
130(2):
512 - 519.
[Abstract]
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H. C. Wijeysundera and D. A. Alter
Is CABG the preferred method of revascularization in multivessel coronary artery disease?
Can. Med. Assoc. J.,
July 19, 2005;
173(2):
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L. E. Jones and C. P. Carney
Mental Disorders and Revascularization Procedures in a Commercially Insured Sample
Psychosom Med,
July 1, 2005;
67(4):
568 - 576.
[Abstract]
[Full Text]
[PDF]
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J. Abrams
Chronic Stable Angina
N. Engl. J. Med.,
June 16, 2005;
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E. L. Hannan, M. J. Racz, G. Walford, R. H. Jones, T. J. Ryan, E. Bennett, A. T. Culliford, O. W. Isom, J. P. Gold, and E. A. Rose
Long-Term Outcomes of Coronary-Artery Bypass Grafting versus Stent Implantation
N. Engl. J. Med.,
May 26, 2005;
352(21):
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[Abstract]
[Full Text]
[PDF]
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R. T. van Domburg, J. J.M. Takkenberg, L. J. Noordzij, F. Saia, L. A. van Herwerden, P. W.J.C. Serruys, and A. J.J.C. Bogers
Late Outcome After Stenting or Coronary Artery Bypass Surgery for the Treatment of Multivessel Disease: A Single-Center Matched-Propensity Controlled Cohort Study
Ann. Thorac. Surg.,
May 1, 2005;
79(5):
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[Abstract]
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[PDF]
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Authors/Task Force Members, S. Silber, P. Albertsson, F. F. Aviles, P. G. Camici, A. Colombo, C. Hamm, E. Jorgensen, J. Marco, J.-E. Nordrehaug, et al.
Guidelines for Percutaneous Coronary Interventions: The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology
Eur. Heart J.,
April 2, 2005;
26(8):
804 - 847.
[Full Text]
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P.-E. Falcoz, S. Chocron, C. Binquet, L. Stoica, D. Kaili, C. Quantin, and J.-P. Etievent
Revascularization of the Right Coronary Artery: Grafting or Percutaneous Coronary Intervention?
Ann. Thorac. Surg.,
April 1, 2005;
79(4):
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[Abstract]
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L. C H John
Cardiac revascularization--a need for independent decision-makers
J R Soc Med,
January 1, 2005;
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1 - 2.
[Full Text]
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G. J Murphy, R. Ascione, and G. D Angelini
Coronary artery bypass grafting on the beating heart: surgical revascularization for the next decade?
Eur. Heart J.,
December 1, 2004;
25(23):
2077 - 2085.
[Abstract]
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[PDF]
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M. S. Chen, E. H. Blackstone, C. E. Pothier, and M. S. Lauer
Heart Rate Recovery and Impact of Myocardial Revascularization on Long-Term Mortality
Circulation,
November 2, 2004;
110(18):
2851 - 2857.
[Abstract]
[Full Text]
[PDF]
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G. J. Murphy, A. J. Bryan, and G. D. Angelini
Hybrid Coronary Revascularization in the Era of Drug-Eluting Stents
Ann. Thorac. Surg.,
November 1, 2004;
78(5):
1861 - 1867.
[Abstract]
[Full Text]
[PDF]
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M. A. Hlatky, D. B. Boothroyd, K. A. Melsop, M. M. Brooks, D. B. Mark, B. Pitt, G. S. Reeder, W. J. Rogers, T. J. Ryan, P. L. Whitlow, et al.
Medical Costs and Quality of Life 10 to 12 Years After Randomization to Angioplasty or Bypass Surgery for Multivessel Coronary Artery Disease
Circulation,
October 5, 2004;
110(14):
1960 - 1966.
[Abstract]
[Full Text]
[PDF]
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R. Kettelkamp, J. House, M. Garg, R. S. Stuart, A. Grantham, and J. Spertus
Using the Risk of Restenosis as a Guide to Triaging Patients Between Surgical and Percutaneous Coronary Revascularization
Circulation,
September 14, 2004;
110(11_suppl_1):
II-50 - II-54.
[Abstract]
[Full Text]
[PDF]
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B. D. Powell, C. S. Rihal, M. R. Bell, K. J. Zehr, and D. R. Holmes Jr
Anticipated Impact of Drug-Eluting Stents on Referral Patterns for Coronary Artery Bypass Graft Surgery: A Population-Based Angiographic Analysis
Mayo Clin. Proc.,
June 1, 2004;
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[Abstract]
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R. H. Jones
The year in cardiovascular surgery
J. Am. Coll. Cardiol.,
May 5, 2004;
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C. S. Rihal, D. L. Raco, B. J. Gersh, and S. Yusuf
Indications for Coronary Artery Bypass Surgery and Percutaneous Coronary Intervention in Chronic Stable Angina: Review of the Evidence and Methodological Considerations
Circulation,
November 18, 2003;
108(20):
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[Full Text]
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Z. Zhang, E. M. Mahoney, R. H. Stables, J. Booth, F. Nugara, J. A. Spertus, and W. S. Weintraub
Disease-Specific Health Status After Stent-Assisted Percutaneous Coronary Intervention and Coronary Artery Bypass Surgery: One-Year Results From the Stent or Surgery Trial
Circulation,
October 7, 2003;
108(14):
1694 - 1700.
[Abstract]
[Full Text]
[PDF]
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