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Outcomes in Patients With Reduced LVEF After PCI vs. CABG
Study Questions:
What are the long-term outcomes in patients with severely reduced left ventricular ejection fraction (LVEF) undergoing revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)?
Methods:
The investigators conducted a retrospective cohort study in Ontario, Canada, from October 1, 2008 to December 31, 2016, and included data from Ontario residents between 40 and 84 years of age with LVEFs <35% and left anterior descending (LAD), left main, or multivessel coronary artery disease (with or without LAD involvement) who underwent PCI or CABG. Exclusion criteria were concomitant procedures, previous CABG, metastatic cancer, dialysis, CABG and PCI on the same day, and emergency revascularization within 24 hours of a myocardial infarction (MI). Data analysis was performed from June 2, 2018 to December 28, 2018. The primary outcome was all-cause mortality. Secondary outcomes were death from cardiovascular disease, major adverse cardiovascular events (MACE; defined as stroke, subsequent revascularization, and hospitalization for MI or heart failure [HF]), and each of the individual MACE.
Results:
A total of 12,113 patients (mean [standard deviation] age, 64.8 [11.0] years for the PCI group and 65.6 [9.7] years for the CABG group; 5,084 [72.5%] male for the PCI group and 4,229 [82.9%] male for the PCI group) were propensity-score matched on 30 baseline characteristics: 2,397 patients undergoing PCI and 2,397 patients undergoing CABG. The median follow-up was 5.2 years (interquartile range, 5.0-5.3). Patients who received PCI had significantly higher rates of mortality (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.3-1.7), death from cardiovascular disease (HR, 1.4; 95% CI, 1.1-1.6), MACE (HR, 2.0; 95% CI, 1.9-2.2), subsequent revascularization (HR, 3.7; 95% CI, 3.2-4.3), and hospitalization for MI (HR, 3.2; 95% CI, 2.6-3.8) and HF (HR, 1.5; 95% CI, 1.3-1.6) compared with matched patients who underwent CABG.
Conclusions:
The authors concluded that higher rates of mortality and MACE were seen in patients who received PCI compared with those who underwent CABG.
Perspective:
This cohort study reports that among patients with coronary artery disease and severely reduced LVEF, there were higher 30-day risks of MACE, subsequent revascularization, and hospitalization for MI or HF among patients who underwent PCI compared to those who underwent CABG. During long-term follow-up, the risks of all-cause death from cardiovascular disease, MACE, subsequent revascularization, and hospitalization for MI or HF were higher among patients who underwent PCI, and was consistent across subgroups. Furthermore, the mortality benefit associated with CABG was consistent in subgroups of patients regardless of the presence of diabetes and was especially evident in those with multivessel disease. Overall these data suggest that clinicians should consider CABG for most patients with severely reduced LV function who require revascularization, which is consistent with current guidelines.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease
Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Heart Failure, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Secondary Prevention, Stroke, Stroke Volume, Ventricular Function, Left
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