In older patients with non-urgent multivessel coronary disease, CABG (probably) has a better long term survival than PCI

It’s been a decade long argument between cardiologists and cardiothoracic surgeons – when it comes to single lesions, PCI is often opted for, and when there are multiple diffuse lesions, CABG is often the choice. It’s not like this hasn’t been looked at before – a few RCTs have suggested different results – but many say these studies are underpowered or too selective. This registry based study from the NEJM aims to end the argument.

Looking at almost 200,000 patients from 2004-2007, they combined two registries, one from the thoracic society and one from the cardiologists. Essentially, they concluded that in patients over 64 years of age, who required revascularisation non-emergently, there was a lower mortality at 4 years in the CABG group compared with PCI.

It’s great that they’ve combined two massive registries – although there are limitations with that – and tried to account for some of the unmeasured confounders, however I’m not entirely sure this ends the argument once and for all. At the end of the day, it is a non-randomised cohort, and patients were different. Selection bias is prevalent in this type of study, particulalry when it comes to cardiology studies.

It is still probably a reasonable result to suggest however in the triple vessel disease group, and several randomised controlled trials show some long term mortality benefit (or at least a trend towards it) in triple vessel disease managed with CABG. Furthermore, you can’t get these kind of numbers in randomised trials, and it’s important to have a mix of both in your evidence base.

For more, the article is here, and there’s a nice editorial from Dr. Mauri here.

 

 

source | NEJM

image | Patrick J. Lynch

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