Late-Breaking Science: CABG or PCI for NSTEMI and multivessel disease?
01 Sep 2024
Late-Breaking Science In a Late-Breaking Science session yesterday, Professor Elmir Omerovic (Sahlgrenska University Hospital - Gothenburg, Sweden) presented results comparing long-term real-world outcomes after coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) in patients with non-ST-elevation acute myocardial infarction (NSTEMI) and multivessel disease.
The researchers used observational data from the SWEDEHEART registry to perform a target trial emulation with instrumental variable analysis to estimate the causal effects of the interventions. Patients with NSTEMI treated with revascularisation in Sweden between January 2005 and June 2022 were included if they had multivessel disease, no cardiogenic shock or cardiac arrest before admission, and no previous stroke, renal failure, cancer or dementia. The primary endpoint was all-cause mortality, with myocardial infarction (MI) and stroke as secondary endpoints.
The analysis included 57,097 patients, with a mean age of 68.7 years. In total, 76% were men, 25% had diabetes, 18% had a previous MI, 16% had left main (LM) disease and 16% had post-infarction heart failure. The primary designated therapy was PCI in 74% of patients and CABG in 26%.
Over a median follow-up time of 7.1 years, there were 17,731 (31%) deaths, 12,765 (22%) MIs and 4,833 (8%) stroke events. The risk of death (adjusted odds ratio [aOR] 1.67; 95% CI 1.54–1.81; p<0.001) and MI (aOR 1.51; 95% CI 1.41–1.62; p<0.001) were higher after PCI than CABG, with no difference for stroke (aOR 0.94; 95% CI 0.85–1.04; p=0.293).
For patients with a life expectancy of ≥15 years after revascularisation, the average lifetime was 6.7 months longer after CABG; however, for those with a life expectancy ≤5 years, it was only 25 days longer after CABG.
The researchers found significant interactions for lower mortality and MI risk with CABG over PCI in patients with left ventricular dysfunction, LM disease, age less than 70 years and later calendar years (all p<0.001). There were no significant interactions between the revascularisation methods for diabetes or sex.
Prof. Omerovic concludes, “CABG was associated with better outcomes compared with PCI overall and our analysis highlights subgroups where CABG was particularly beneficial, namely in those with LV dysfunction, LM disease, younger age and longer life expectancy.”
