What are the comparative outcomes of Percutaneous Coronary Intervention (PCI) versus Coronary Artery Bypass Grafting (CABG) studies?

From the Guidelines

CABG is the preferable option for patients with diabetes and multivessel disease, including the LAD, who have acceptable surgical risk, due to its association with lower rates of major adverse cardiac events, repeat revascularization, and mortality, as demonstrated in recent studies such as the FREEDOM trial 1.

Key Considerations

• The choice between PCI and CABG depends on various factors, including coronary complexity, comorbidities, and patient preferences.
• CABG is generally recommended for patients with complex coronary artery disease, particularly those with diabetes or left main coronary artery disease, due to its superior long-term outcomes.
• PCI offers advantages of being less invasive with shorter recovery times and fewer short-term complications, making it preferable for patients with limited disease, high surgical risk, or those needing immediate intervention.

Comparative Outcomes

• Studies have consistently shown that CABG is associated with lower rates of major adverse cardiac events, repeat revascularization, and mortality in patients with multivessel disease, particularly those with diabetes or left main coronary artery disease 1.
• The FREEDOM trial demonstrated that CABG is associated with a lower all-cause mortality rate and decreased repeat revascularizations compared to PCI in patients with diabetes and multivessel disease 1.
• A meta-analysis of randomized trials confirmed that CABG provides better long-term protection against myocardial infarction and repeat procedures, especially in complex anatomical scenarios 1.

Patient Selection

• Patient selection remains crucial, with heart team discussions recommended to individualize treatment based on coronary complexity, comorbidities, and patient preferences.
• The choice of revascularization in patients with CAD and LV systolic dysfunction is best based on clinical variables, magnitude of LV systolic dysfunction, patient preferences, clinical judgment, and consultation between the interventional cardiologist and the cardiac surgeon 1.

From the Research

Comparative Outcomes of PCI and CABG

• The study published in 2 found that CABG remains the standard of care for patients with three-vessel or left main coronary artery disease, as it resulted in lower rates of major adverse cardiac or cerebrovascular events at 1 year compared to PCI.
• In contrast, the case report in 3 suggests that PCI may be a viable alternative to CABG in specific high-risk patients with diabetes, left main coronary artery disease, and multivessel disease, although this is not a widely accepted view.
• A review of the evidence in 4 found that CABG is associated with better survival, lower rates of major cardiovascular events, and repeat revascularization compared to PCI with drug-eluting stents in patients with multivessel disease.
• The review in 5 suggests that CABG may differ from PCI by providing "surgical collateralization," which can prolong life by preventing myocardial infarctions, whereas PCI is solely focused on treating flow-limiting lesions.
• The analysis from the ACUITY trial in 6 found that among patients with acute coronary syndrome and proximal left anterior descending artery lesions, PCI and CABG had similar 1-year death, myocardial infarction, and major adverse cardiac event rates, although unplanned revascularization was more common after PCI.

Key Findings

• CABG is generally considered the standard of care for patients with complex coronary artery disease, although PCI may be a viable alternative in certain high-risk patients.
• The choice between PCI and CABG depends on various factors, including the patient's anatomical and clinical characteristics, as well as the local expertise and resources available.
• Further research is needed to determine the optimal revascularization strategy for patients with different types and severity of coronary artery disease.

Outcomes by Patient Subgroup

• Patients with diabetes and left main coronary artery disease may benefit from CABG, although PCI may be a viable alternative in certain cases 3.
• Patients with multivessel disease may benefit from CABG, which is associated with better survival and lower rates of major cardiovascular events compared to PCI 4.
• Patients with acute coronary syndrome and proximal left anterior descending artery lesions may have similar outcomes with PCI and CABG, although unplanned revascularization is more common after PCI 6.