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NEWS
Kevin Johns receives the John Hinckley Lifetime Outstanding Service Award
Pro/Con
Mitral Regurgitation Can Be Reliably Assessed In The Operating Room Under General Anesthesia
Literature Reviews
Acute Kidney Injury After Cardiac Surgery Focus on Modifiable Risk Factors
Intensive versus Conventional Glucose Control in Critically Ill Patients
Glycemic variability: A strong independent predictor of mortality in critically ill patients
Foundation Update
SCA Foundation to host reception honoring Michael Roizen on Sunday, April 19
The Society of Cardiovascular Anesthesiologists (SCA) publishes the SCA Bulletin bimonthly. The information presented in the SCA Bulletin has been obtained by the editors. Validity of opinions presented, drug dosages, accuracy and completeness of content are not guaranteed by SCA.
Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease
Serruys PW, Morice MC, Kappetein AP, et al.
N Engl J Med 2009; 360: 961-72.
Reviewed by: Hong Liu, MD
UC Davis Health System, Sacramento, CA
Objectives and Background
Percutaneous coronary intervention (PCI) involving drug-eluting stents is increasingly used to treat complex coronary artery disease, although coronary artery bypass grafting (CABG) has been the treatment of choice historically. This trial compared PCI and CABG for treating patients with previously untreated three-vessel or left main coronary artery disease (or both).
Methods
The authors randomly assigned 1800 patients with three-vessel or left main coronary artery disease (CAD) to undergo CABG or PCI (in a 1:1 ratio). For all patients, the local cardiac surgeon and interventional cardiologist determined that equivalent anatomical revascularization could be achieved with either treatment. A noninferiority comparison of the two groups was performed for the primary end point — a major adverse cardiac or cerebrovascular event (i.e., death from any cause, stroke, myocardial infarction, or repeat revascularization) during the 12-month period after randomization. Patients for whom only one of the two treatment options would be beneficial, because of anatomical features or clinical conditions, were entered into a parallel, nested CABG or PCI registry.
Results and Conclusions
Most of the preoperative characteristics were similar in the two groups. Rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the PCI group (17.8%, vs. 12.4% for CABG; P=0.002), in large part because of an increased rate of repeat revascularization (13.5% vs. 5.9%, P<0.001); as a result, the criterion for noninferiority was not met. At 12 months, the rates of death and myocardial infarction were similar between the two groups; stroke was significantly more likely to occur with CABG (2.2%, vs. 0.6% with PCI; P=0.003). The authors concluded that CABG remains the standard of care for patients with three-vessel or left main CAD, since the use of CABG, as compared with PCI, resulted in lower rates of the combined end point of major adverse cardiac or cerebrovascular events at 1 year.
CABG was introduced in 1968 and rapidly became the standard of care for symptomatic patients with CAD. Since the introduction of PCI in 1977 and with the great improvement in technology, PCI has been used to treat increasingly complex lesions and patients with a history of clinically significant cardiac disease, risk factors for coronary artery disease, coexisting conditions, or anatomical risk factors. There are many clinical studies comparing CABG and PCI, but most of these studies were smaller and nonrandomized. In this international, multicenter, randomized, controlled comparison of CABG vs. PCI with drug-eluting stents in 1800 patients, all of them with left main or three-vessel CAD, CABG was proven to be superior to PCI for the primary end point, the 12-month rate of major adverse cardiac or cerebrovascular events. This was mainly driven by the increased need for revascularization in the PCI group. For the secondary outcomes, the results were mixed. The authors designed SYNTAX score to predict outcomes related to anatomical characteristics and, to a lesser extent, the functional risk of occlusion for any segment of the coronary-artery bed. There was also a significant relationship between SYNTAX score and treatment group. Patients with low or intermediate scores in the CABG group and in the PCI group had similar rates of major adverse cardiac or cerebrovascular events, whereas among patients with high scores, the event rate was significantly increased in the PCI group. Although this study provides important information about current treatment of CAD, there are limitations. First, the 12-month follow-up period may not be sufficient to reflect the true long-term effect of CABG as compared with PCI with drug-eluting stents on cardiac-related health. Second, the use of antiplatelet medication was high among patients in the PCI group. Third, more patients withdrew, after randomization, from the CABG group than from the PCI group. From this 12-month study, CABG remains the standard of care for patients with three-vessel or left main CAD. This study was also designed to have a 4-year follow-up period, so that we’ll be able to see the outcomes over a longer period of time.