Original title: Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final five-year follow-up of the SYNTAX trial. Reference: Eur Heart J. 2014 May 21. pii: ehu213. (Epub ahead of print).
The SYNTAX study was one of the largest randomized clinical studies comparing long-term results of angioplasty versus surgery in multivessel disease and /or injury of left main coronary artery patients. At one year failed to show non-inferiority of angioplasty, however the main legacy of this study is probably the SYNTAX score. After the publication of the SYNTAX both the American and European guidelines their recommendations changed and angioplasty emerged as an option for patients with less complex anatomy (SYNTAX Score <23).
Final results are now presented after five years from 1095 patients with left main coronary artery and /or multiple vessels randomized to receive angioplasty using 1st generation paclitaxel-eluting stent (Taxus) versus CABG. Overall patients receiving angioplasty had a higher rate of combined end point of cardiovascular and cerebrovascular events MACCE (37.5 versus 24.2%, P <0.001), as well as a higher rate of combined death / myocardial infarction / stroke (22% versus 14%, p <0.001), death from any cause (14.6% versus 9.2%, P = 0.006), myocardial infarction (9.2% versus 4%, P = 0.001) and repeat revascularization (25.4% versus 12.6%; p <0.001).
The stroke rate at five years was similar between both strategies (3% versus 3.5%, P = 0.66). These overall results were modified to evaluate the data according to the anatomical complexity in patients with low SYNTAX score (0-22) both methods resulted in a similar rate of MACCE (33.3% versus 26.8%, P = 0.21) but with a higher rate of repeat revascularization for those receiving angioplasty (25.4 versus 12.6%, P = 0.038).
Regarding intermediate scores (23-32), or higher (≥ 23) CABG proved to be superior in terms of MACCE, mortality, and myocardial revascularization and these differences were even larger in the diabetic population.
Conclusion
After 5-year, surgery proved superior to angioplasty using 1st generation pharmacological stent in patients with multivessel coronary disease. In those with low SYNTAX score, angioplasty proved to be an acceptable strategy to the cost of a new higher rate of revascularization.
Editorial comment
Often happens with such long-term studies that devices, drugs or strategies used at the time of randomization are out-dated at the time of publication. The latter is also true for the SYNTAX study where pharmacological 1st generation stents used demonstrated to be inferior in terms of in-stent thrombosis, myocardial infarction reduction and new revascularization compared to newer devices and also the decision to revascularize or not the vessel was taken with angiography and not with fractional flow reserve (FFR) that has also shown to reduce events.
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