Lancet: Meta-analysis shows CABG better than PCI in diabetics, older patients

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Barring elderly and diabetic patients, long-term mortality is similar after CABG and PCI in most other patients with multivessel coronary artery disease. Treatment choice, therefore, should depend on patient preferences, according to a collaborative analysis published in the April issue of Lancet.

Mark A. Hlatky, MD, from Stanford University School of Medicine in Stanford, Calif., and colleagues gathered data from 10 randomized trials on 7,812 patients to assess whether the effects of the CABG compared with PCI on mortality are modified by patient characteristics.

The researchers pooled individual patient data from ten randomized trials to compare the effectiveness of CABG with PCI according to patients' baseline clinical characteristics. They used stratified, random effects Cox proportional hazards models to test the effect on all-cause mortality of randomized treatment assignment and its interaction with clinical characteristics. PCI was done with balloon angioplasty in six trials and with bare-metal stents in four trials.

Over a median follow-up of 5.9 years, the investigators found that 15 percent of 3,889 patients assigned to CABG died compared with 16 percent of 3,923 patients assigned to PCI. In patients with diabetes (CABG 615; PCI 618), mortality was substantially lower in the CABG group than in the PCI group; however, mortality was similar between groups in patients without diabetes.

Patient age modified the effect of treatment on mortality, with hazard ratios of 1.25 in patients younger than 55 years, 0.90 in patients aged 55-64 years, and 0.82 in patients 65 years and older, according to the authors. Treatment effect was not modified by the number of diseased vessels or other baseline characteristics.

Hlatky and colleagues concluded that CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups.

The Agency for Healthcare Research and Quality funded the study.