NEJM: CABG proves more efficacious than drug-eluting stents

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For patients with multi-vessel disease, coronary-artery bypass grafting continues to be associated with lower mortality rates than treatment with drug-eluting stents and is also associated with lower rates of death or myocardial infarction and repeat revascularization, according to a study in the Jan. 25 issue of The New England Journal of Medicine.

Numerous studies have compared the outcomes of CABG and coronary stenting. However, little information has become available since the introduction of drug-eluting stents, according to Edward L. Hannan, PhD, in the department of health policy, management, and behavior at the University at Albany.

Hannan and colleagues compared adverse outcomes (death, death or myocardial infarction, or repeat revascularization) through December 2005 in 17,400 N.Y. patients who received drug-eluting stents (DES) or underwent CABG between October 2003 and December 2004.

CABG was associated with lower 18-month rates of death and of death or MI both for patients with three-vessel disease and for patients with two-vessel disease compared with treatment with DES.

Among patients with three-vessel disease who underwent CABG, as compared with those who received a stent, the adjusted hazard ratio for death was 0.80 and the adjusted survival rate was 94% versus 92.7%; the adjusted hazard ratio for death or MI was 0.75 and the adjusted rate of survival free from MI was 92.1% versus 89.7%.

Among patients with two-vessel disease who underwent CABG, as compared with those who received a stent: the adjusted hazard ratio for death was 0.71 and the adjusted survival rate was 96% versus 94.6% the adjusted hazard ratio for death or MI was 0.71 and the adjusted rate of survival free from MI was 94.5% versus 92.5%.

“The finding is far from the last word on the stent-versus-surgery debate in such cases. But there isn't any other study right now that is better than this,” Hannan told the Washington Post. “Physicians need to inform patients about these results and need to engage in a dialogue that includes these findings to determine what is the proper treatment for multi-vessel disease.”

To date, no large studies have directly compared long-term outcomes after CABG with those after DES treatment, leaving the possibility that the benefits of DES implantation are attenuated due to an increased risk of late stent thrombosis.

Domestic sales of DES fell about 30 percent in 2007 after they were linked to thrombosis, and some studies suggested drug therapy might be as effective.

“The absolute mortality difference seen in this trial was relatively small and may not be real because prior randomized controlled clinical trials have not found such a difference. Even in diabetic patients, a recently published meta-analysis of angioplasty vs. surgery randomized trials found no differences in survival. We must await the large scale randomized trials [SYNTAX and FREEDOM] to more definitively answer this question,” Gregg W. Stone, MD, of Columbia University Medical Center in New York City told TCTMD.