CABG vs. stenting

There's an excellent roundtable discussion on outcomes of coronary artery bypass graft (CABG) surgery vs percutaneous coronary intervention (PCI) in this week's New England Journal of Medicine. On the panel are Elizabeth Nabel, David Hillis, and Tom Lee. I had a chance to spend some time with the Nabel family last year -- she's a terrific cardiologist and currently Director of the National Heart, Lung, and Blood Institute.

Link to video after the jump.

In the international SYNTAX trial (ClinicalTrials.gov number, NCT00114972), funded by Boston Scientific (manufacturers of the TAXUS drug-eluting stent), 1800 patients with three-vessel or left main disease were randomly assigned to either revascularization with CABG or PCI involving drug-eluting stents. The paper published in NEJM (Serruys P et al. N Engl J Med 2009) shows us these dramatic Kaplan-Meir curves by treatment group:


The need for repeat revascularization was significantly lower with CABG, but the risk of stroke was significantly higher in the surgery group.

As Dr. Mohammadzadeh of CA has pointed out,

Many of the commentators have cited the difference in stroke rates in the two study groups as a justification for choosing pci over cabg. I do not see how their argument holds when there was such a vast difference between the post-procedural medical therapy that the two groups received. It seems to make good intuitive sense that if the surgical group had received as aggressive medical therapy, that not only the stroke rates may have been comparable, but the other end points such as mace would have crystallize more strikingly in favor of the surgical group. There is no question that there are patients that are better served by pci even in the setting of LM stenosis or 3-V CAD, but the bottom line should be that the patients should be given a fair and balanced explanation of their options before making a decision that is best suited for them.

Exactly. The risk vs. benefit analysis has long favored CABG in three vessel or LM disease, and this study should not really change clinical practice in these circumstances. However, it is striking that CABG patients often receive subpar antiplatelet therapy on the surgical floor. Establishing clinical directives for aggressive medical therapy in CABG patients might produce a welcome drop in stroke risk and rates of repeat revascularization.

And let's not forget that, despite the heated rhetoric surrounding this trial, we're really not considering one treatment strategy versus another. PCI has a secure and well-established place in the treatment of stable angina due to CAD.