Coronary Artery Disease
Comparison of Intermediate-Term Outcomes of Coronary Artery Bypass Grafting Versus Drug-Eluting Stents for Patients ≥75 Years of Age

https://doi.org/10.1016/j.amjcard.2013.11.035Get rights and content

Several randomized controlled trials and observational studies have compared outcomes of percutaneous coronary interventions (PCIs) with drug-eluting stents (DESs) and coronary artery bypass grafting (CABG), but they have not thoroughly investigated the relative difference in outcomes for patients aged ≥75 years. In this study, a total of 3,864 patients receiving DES and CABG (1,932 CABG-DES pairs) with multivessel coronary disease were propensity matched using multiple patient risk factors and were compared with respect to 3 outcomes (mortality, stroke/myocardial infarction [MI]/mortality, and repeat revascularization) at 2.5 years with a mean follow-up of 18 months. The mortality rates (DES/CABG hazard ratio 1.06, 95% confidence interval 0.87 to 1.30) and the stroke/MI/mortality rates (DES/CABG hazard ratio 1.15, 95% confidence interval 0.97 to 1.38) for the 2 procedures were not significantly different. Repeat revascularization rates were significantly higher for patients who received DESs. In conclusion, older patients experienced similar mortality and stroke/MI/mortality rates for CABG and PCI with DES, although repeat revascularization rates were higher for patients undergoing PCI with DES.

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Methods

End points in the study included 2.5-year mortality, stroke/myocardial infarction (MI)/mortality, and repeat revascularization. The mean follow-up time was 1.5 years; all procedures performed from January 1, 2008 to December 31, 2010 were followed through December 31, 2010.

The primary databases used for the study were New York State's clinical registries for PCI and for CABG, the Percutaneous Coronary Interventions Reporting System (PCIRS) and the Cardiac Surgery Reporting System (CSRS),

Results

A total of 6,927 patients aged ≥75 years (4,299 patients who received DES and 2,628 CABG) were subjected to propensity matching and 3,864 patients (1,932 pairs and 74% of all patients receiving CABG) were propensity matched. The variables used in the propensity model are all the variables in Table 1, and the C statistic for the models was 0.81.

Table 1 presents differences in patient characteristics for patients receiving DES and CABG in New York from 2008 to 2010. As indicated, older patients,

Discussion

Numerous comparative effectiveness studies have been conducted to compare outcomes of CABG and PCI with stents for patients with multivessel coronary artery disease.6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 However, there is a need to continually update studies of this nature because of the evolution of the 2 procedures, particularly PCI, which has evolved from balloon angioplasty to bare-metal stenting to multiple generations of DES.

In 2009, Hlatky et al9 pooled data from 10

Acknowledgment

The authors thank New York State's Cardiac Advisory Committee (CAC) for their encouragement and support of this study and Kimberly S. Cozzens, MA and Cynthia Johnson and the cardiac catheterization laboratories of the participating hospitals for their tireless efforts to ensure the timeliness, completeness, and accuracy of the registry data.

References (21)

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    At a mean follow-up of 18 months, they found no difference in mortality (HR 1.06, 95% CI: 0.87 to 1.30, p = 0.58) or combined stroke, MI, and mortality (HR 1.15, 95% CI: 0.97 to 1.38, p = 0.12); however, there was a significant difference in revascularization associated with CABG (DES versus CABG HR 7.48, 95% CI: 5.61 to 9.98, p < 0.0001). The lack of mortality difference between CABG and DES demonstrated by Hannan and colleagues [19] mirrors the results of our analysis. Although CABG is associated with a reduction in combined cardiovascular endpoints, there may not be an associated mortality benefit in the elderly when compared with newer generation DES.

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This work was supported by grant RC1HL099122 from the National Institutes of Health, Bethesda, Maryland.

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