Original title: Everolimus-Eluting Stents or Bypass Surgery for Multivessel Coronary Disease. Reference: Sripal Bangalore, M.D. et al. N Engl J Med. 2015 Mar 26;372(13):1213-22.

Coronary artery bypass grafting (CABG) have had better outcomes than percutaneous coronary intervention (PCI) in the treatment of multivessel coronary disease.  However, this information comes from studies that do not include new generation stents. The aim of this study is to compare CABG vs. everolimus eluting stenting in patients with multivessel disease.

This New York registry included multivessel disease patients; 9223 were treated with PCI and 9223 with CABG; follow up was 2.9 years. Propensity score matching was used to assemble patient cohorts of similar characteristics. Primary end point was all cause mortality and secondary end points were: acute myocardial infarction (AMI), stroke and repeat revascularization.

There were no significant differences in mortality between the groups (3.1 % for PCI vs 2.9 % for CABG per year; p = 0.5). The risk of spontaneous AMI (not associated to procedure) was higher in the PCI group (1.9% vs 1.1% per year; p < 0.001), but when complete revascularization was performed, this difference disappeared. PCI was associated to a significant lower risk of stroke (0.7 % vs 1.0 % per year; p < 0.001) and a higher incidence of repeat revascularization (7.2 % vs 3.1 % per year, p < 0.001).

Conclusion

In this contemporary clinical practice study of patients with multiple vessel disease comparing PCI with everolimus eluting stents vs. CABG, everolimus eluting stenting was associated with a similar risk of death, a lower risk of stroke and higher risk of repeat revascularization and infarction.

Editorial Comment

This large registry has enough statistical power and provides information about mortality, AMI and the need of repeat revascularization with no need to analyze combined end points. It shows the importance of a complete percutaneous revascularization and this suggests a possible strategy to treat multivessel disease in the clinical practice. If possible, mortality and AMI rates will be similar with both treatments PCI and CABG, with lower stroke and higher repeat revascularization rates for PCI. If not possible, mainly because of anatomical conditions, mortality, AMI and repeat revascularization rates are lower with CABG. This strategy is in line with the SYNTAX outcomes, where low anatomical complexity (possibility of complete revascularization) have similar mortality outcomes. 

Courtesy of Drs. Pedro Trujillo and Juan Pablo Bachini.
Montevideo, Uruguay.

Pedro Trujillo – Juan Pablo Bachini