Original Title: Revascularization in Patients with Multivessel Coronary Artery Disease and Severe Left Ventricular Systolic Dysfunction: Everolimus Eluting Stents vs Coronary Artery Bypass Graft Surgery

Reference: Bangalore et al. Circulation. 2016 May 5. Epub ahead of print.

Courtesy of Dr. Guillermo Migliaro.

Guidelines recommend coronary artery bypass graft surgery (CABG) over percutaneous coronary intervention (PCI) for multivessel disease and severe left ventricular (LV) systolic dysfunction. However, to date, there are no randomized studies comparing both strategies in these patients, since, in general, LV systolic dysfunction will automatically exclude them.

The aim of this study is to compare the clinical efficacy of CABG vs. PCI in patients with multivessel and severe LV dysfunction.

This is an observational retrospective study including patients from the New York State surgery and PCI registries (n= 4616) with multivessel disease (except those with left main lesion) and ejection fraction lower than 35% that had undergone PCI with everolimus eluting stents or CABG. Patients included in the study were matched using propensity score (n= 1063 in each group). Primary end point was all cause mortality at long term and secondary end points were acute myocardial infarction (AMI), stroke and repeat revascularization.

Mortality at 30 days was not significantly different between the groups (HR=0.62; 95% CI 0.31-1.24; p=0.17) neither was AMI (HR=1.60; 95% CI 0.52-4.89; p=0.41).

PCI presented lower risk of stroke (0.1% vs 1.8%; HR=0.05; 95% CI 0.01-0.39; p=0.004).

At long term, (median 2.9 years) mortality was similar in both groups, with no statistically significant differences (HR=1.01; 95% CI 95% 0.81-1.28; p=0.91). PCI presented higher risk of AMI (HR=2.16; 95% CI 1.42-3.28; p=0003) only in the subgroup of patients which had not received complete revascularization (interaction test p=0.002). PCI also showed higher risk of repeat revascularization (HR=2.54; 95%IC 95% 1.88-3.44 p<0.0001) and lower risk of stroke (HR 0.57; 95% CI 0.33-0.97; p=0.04).

Conclusion

In patients with multivessel disease and depressed systolic function, PCI with everolimus eluting stents have a survival rate comparable to that of surgery. PCI presented higher risk of AMI in the subgroup of patients with incomplete revascularization and lower risk of stroke, compared to CABG.

Editorial Comment

This is an observational study (though with perfectly balanced groups), which is common to studies that are not randomized.

It does not take into account the anatomical features of coronary angiographies (such as the Syntax score) or an estimation of clinical risk (such as STS or EuroScore)

Neither does it inform on procedure characteristics, number of implanted stents, the use of coronary intravascular ultrasound or optical coherence tomography for procedure optimization, or the number of arterial and venous grafts. It does not report the use of FFR as a guide (functional revascularization) or the presence or absence of feasibility. Neither does it specify the antiplatelet regime or its duration.

Since there is no evidence from randomized studies, the present study is a hypothesis generator and should be corroborated by further research on a large scale.

Courtesy of Dr. Guillermo Migliaro.