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PCI vs. CABG for NSTEMI With Multivessel CAD
Quick Takes
- The current study was a retrospective analysis of a Swedish, predominantly male population comparing outcomes for PCI vs. CABG among patients with NSTEMI and multivessel CAD.
- From 2005 to 2022, the majority of patients in the SWEDEHEART registry with NSTEMI and multivessel CAD underwent PCI (74% vs. 26%). PCI was associated with higher risks of death, MI, and repeat revascularization compared to CABG.
- The survival benefit of CABG was most pronounced in patients <70 years, and those with left main disease, LV dysfunction, and longer life expectancy.
Study Questions:
What are the long-term outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and multivessel disease?
Methods:
The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry was used to analyze 57,097 revascularized patients with NSTEMI with multivessel disease in Sweden from January 2005 to June 2022. The primary endpoint was all-cause mortality, encompassing both in-hospital and long-term mortality; the secondary endpoints included myocardial infarction (MI), stroke, new revascularization, and heart failure (HF). Multilevel logistic regression with follow-up time as a log-transformed offset variable and double-robust adjustment with the instrumental variable method were applied to control for known and unknown confounders.
Results:
PCI was the primary therapy in 42,190 (73.9%) patients, while 14,907 (26.1%) received CABG. PCI patients were generally older with more prior cardiovascular events, whereas CABG patients had a higher incidence of diabetes, hypertension, left main and three-vessel disease, and reduced ejection fraction. Over a median follow-up of 7.1 years, PCI was associated with higher risks of death (adjusted odds ratio [aOR], 1.67; 95% confidence interval [CI], 1.54–1.81) and MI (aOR, 1.51; 95% CI, 1.41–1.62) but there was no significant difference in stroke. Repeat revascularization was three times more likely to include PCI (aOR, 3.01; 95% CI, 2.57–3.51), while HF risk was 15% higher (aOR, 1.15; 95% CI, 1.07–1.25). CABG provided longer survival within 15 years, especially in patients <70 years of age, with left main disease or left ventricular (LV) dysfunction, though this benefit diminished over shorter time horizons.
Conclusions:
CABG is associated with lower risks of mortality, MI, repeat revascularization, and HF in patients with NSTEMI, particularly in high-risk subgroups. However, its survival benefit lessens with shorter life expectancy.
Perspective:
The current study was a retrospective analysis of a Swedish, predominantly male population comparing outcomes for PCI versus CABG among patients with NSTEMI and multivessel coronary artery disease (CAD). From 2005 to 2022, the majority of patients in the SWEDEHEART registry with NSTEMI and multivessel CAD underwent PCI (74% vs. 26%). PCI was associated with higher risks of death (aOR, 1.67 [1.54–1.81]), MI (aOR, 1.51 [1.41–1.62]), and repeat revascularization (aOR, 3.01 [2.57–3.51]) compared to CABG. The survival benefit of CABG was most pronounced in patients <70 years of age, and those with left main disease, LV dysfunction, and longer life expectancy. The study design, with potential for residual confounding and broad time spectrum during which significant changes to practice have occurred, limit the conclusions from the current analysis. Findings lend strong support to a heart team approach when considering revascularization options for patients with NSTEMI and multivessel CAD.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery
Keywords: Coronary Artery Bypass, Myocardial Revascularization, Percutaneous Coronary Intervention
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