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Original Investigation |

Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention and Long-term Mortality and Morbidity in Multivessel Disease:  Meta-analysis of Randomized Clinical Trials of the Arterial Grafting and Stenting Era FREE

Ilke Sipahi, MD1,2; M. Hakan Akay, MD3; Sinan Dagdelen, MD1; Arie Blitz, MD2; Cem Alhan, MD3
[+] Author Affiliations
1Department of Cardiology, Acibadem University Medical School, Istanbul, Turkey
2Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
3Department of Cardiovascular Surgery, Acibadem University Medical School, Istanbul, Turkey
JAMA Intern Med. 2014;174(2):223-230. doi:10.1001/jamainternmed.2013.12844.
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Published online

Importance  Recent trials of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) for multivessel disease were not designed to detect a difference in mortality and therefore were underpowered for this outcome. Consequently, the comparative effects of these 2 revascularization methods on long-term mortality are still unclear. In the absence of solid evidence for mortality difference, PCI is oftentimes preferred over CABG in these patients, given its less invasive nature.

Objectives  To determine the comparative effects of CABG vs PCI on long-term mortality and morbidity by performing a meta-analysis of all randomized clinical trials of the current era that compared the 2 treatment techniques in patients with multivessel disease.

Data Sources  A systematic literature search was conducted for all randomized clinical trials directly comparing CABG with PCI.

Study Selection  To reflect current practice, we included randomized trials with 1 or more arterial grafts used in at least 90%, and 1 or more stents used in at least 70% of the cases that reported outcomes in patients with multivessel disease.

Data Extraction  Numbers of events at the longest possible follow-up and sample sizes were extracted.

Data Synthesis  A total of 6 randomized trials enrolling a total of 6055 patients were included, with a weighted average follow-up of 4.1 years. There was a significant reduction in total mortality with CABG compared with PCI (I2 = 0%; risk ratio [RR], 0.73 [95% CI, 0.62-0.86]) (P < .001). There were also significant reductions in myocardial infarction (I2 = 8.02%; RR, 0.58 [95% CI, 0.48-0.72]) (P < .001) and repeat revascularization (I2 = 75.6%; RR, 0.29 [95% CI, 0.21-0.41]) (P < .001) with CABG. There was a trend toward excess strokes with CABG (I2 = 24.9%; RR, 1.36 [95% CI, 0.99-1.86]), but this was not statistically significant (P = .06). For reduction in total mortality, there was no heterogeneity between trials that were limited to and not limited to patients with diabetes or whether stents were drug eluting or not. Owing to lack of individual patient-level data, additional subgroup analyses could not be performed.

Conclusions and Relevance  In patients with multivessel coronary disease, compared with PCI, CABG leads to an unequivocal reduction in long-term mortality and myocardial infarctions and to reductions in repeat revascularizations, regardless of whether patients are diabetic or not. These findings have implications for management of such patients.

Figures in this Article

Despite advances in medical, surgical, and percutaneous therapies, coronary artery disease (CAD) remains a leading cause of death in the Western world as well as many in developing countries. One of every 6 deaths in the United States is caused by CAD. Approximately every 25 seconds, an American will have a coronary event, and approximately every minute, someone will die of one.1

The optimal treatment approach for patients with multivessel coronary disease remains unclear despite a myriad of randomized clinical trials performed in the last several decades. Several contemporary trials comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) have reported similar mortality rates with the 2 treatment techniques.211 These trials have also reported similar myocardial infarction (MI) rates with the 2 treatment approaches,4,611 although a longer-term follow-up of one of these trials suggested a reduction in MIs with CABG.12 Given no clear superiority of surgical treatment with regard to mortality and MIs, and given an increase in early strokes with CABG,9 PCI is often preferred in patients with multivessel CAD. Accordingly, between 2001 and 2006, the number of PCIs performed annually for multivessel disease increased by 56%, and the total number of CABG surgeries decreased by 24% and continued to decline at a rate of approximately 5% per year subsequently.13

Despite the large number of clinical trials comparing CABG with PCI for multivessel disease, all of these trials were underpowered to detect a difference in all-cause mortality, the most important outcome of cardiovascular trials.2,6,7,911 Similarly, these trials were also underpowered to detect differences in MI, a major cause of morbidity in these patients. Consequently, the current practice regarding treatment of multivessel coronary disease is not evidence based for hard end points. Therefore, our aim was to overcome the power limitation of the existing data sets by performing a meta-analysis all randomized trials directly comparing CABG with PCI in the current era of high arterial graft and stent use and examine the comparative effects of these procedures on long-term mortality and morbidity in patients with multivessel disease.

Literature Search

A systematic search was made of MEDLINE using PubMed through December 2012 to retrieve all published “randomized controlled trials” comparing CABG and PCI in multivessel coronary disease. The search term was [(bypass or by-pass) and (PCI or stent) and (multi-vessel or multivessel or three-vessel or three vessel or two vessel or two-vessel)]. The search was limited to “randomized controlled trials,” and there was no time limit used in the search criteria. Supplementary searches were made using Scopus (covering MEDLINE, Embase, and several other databases from a variety of disciplines) and Cochrane Central Register of Controlled Trials using similar search terms.

Study Selection

All of the 102 publications retrieved from the PubMed-MEDLINE search were reviewed carefully for exclusion criteria. Studies were excluded if they (1) were not randomized, (2) did not have a dedicated CABG and PCI arm, (3) did not report mortality, (4) did not report outcomes in patients with multivessel disease, (5) had an average follow-up duration shorter than 1 year, (6) did not use at least 1 arterial graft in at least 90% of the patients receiving CABG, and (7) did not use stents in at least 70% of the patients in the PCI arm. The last 2 exclusion criteria were chosen to assure that the included clinical trials reflected the current clinical practice.

Data Extraction

Data from studies meeting the selection criteria were extracted and verified independently by 2 of us (I.S. and M.H.A.). Information on inclusion criteria, duration of follow-up, procedural characteristics, and baseline patient characteristics were collected. Subsequently, number of events and total sample size for the outcomes of interest according to treatment arms at the longest possible follow-up were extracted for each trial. If the actual numbers of events were not stated, Kaplan-Meier estimates were used.

Statistical Analysis

Statistical heterogeneity was tested by the Cochran Q statistic and was reported as I2. To obtain meta-analytic risk ratios (RRs) and 95% CIs, fixed effects models using number of events and total sample size were used, unless there was heterogeneity among the included trials. In cases of heterogeneity (defined as I2 > 40%), random effects models were used. Sensitivity analyses were performed according to whether trials were limited or not limited to diabetics, whether bare-metal or drug-eluting stents were used, and by using the one-study-out method. To address the issue of publication bias, the Begg-Rank correlation method was used.14 The reported P values with this method are 2-tailed, with continuity correction. Additionally, funnel plots were generated to further examine publication bias. Comprehensive Meta Analysis software, version 2.2.064 (Biostat Inc) was used for all analyses.The PRISMA checklist for this meta-analysis can be found in the eTable in the Supplement.

Search Results

The results of the literature search are shown in Figure 1. Of the 102 results, 6 clinical trials without the exclusion criteria enrolling a total of 6055 patients (3023 CABG, 3032 PCI) were included in the meta-analysis. Supplementary searches of Scopus and Cochrane Central Register of Controlled Trials did not reveal any additional relevant data.

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Figure 1.
Flowchart of Trials Included in the Meta-analysis

For study acronym expansions, see the cited references.

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Study and Patient Characteristics

The characteristics of the included trials are listed in Table 1. The duration of longest follow-up varied between 1 and 6 years, with a weighted average of 4.1 years. The CARDia7 and FREEDOM16 trials were limited to patients with diabetes, and the remaining 4 trials enrolled mostly nondiabetic patients (77% nondiabetic). The SYNTAX9 and FREEDOM16 trials used only drug-eluting stents; ARTS,11 MASS II,6 and SoS2 used only bare-metal stents; and CARDia7 used both. Use of off-pump CABG was 0% to 31% in the included trials. Baseline patient characteristics are listed in Table 2 and Table 3. These were similar in the CABG and PCI arms of the individual studies, as expected in large randomized trials. Left ventricular systolic function was preserved in most patients. Patients had either 2-vessel or 3-vessel coronary disease in all trials except the SYNTAX trial multivessel group,9 where all patients had 3-vessel disease.

Table Graphic Jump LocationTable 1.  Characteristics of Randomized Trials of CABG vs PCI in Patients With Multivessel Disease Included in The Meta-analysis
Table Graphic Jump LocationTable 2.  Characteristics of Patients Enrolled in Randomized Trials of CABG vs PCI in Patients With Multivessel Disease Included in the Meta-analysisa
Table Graphic Jump LocationTable 3.  Disease Types in Patients Enrolled in Randomized Trials of CABG vs PCI in Patients With Multivessel Disease Included in the Meta-analysisa

No evidence of publication bias was detected when this issue was examined by the Begg-Rank correlation method. The test statistic for the Begg approach, the Kendall τ, was nonsignificant for reporting of mortality and MI (P > .80 for both mortality and MI). Funnel plots examining publication bias are presented in Figure 2.

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Figure 2.
Funnel Plots Examining Publication Bias for Mortality (A) and Myocardial Infarction (B)

Log risk ratios less than 0 favor coronary artery bypass grafting; those greater than 0 favor percutaneous coronary intervention. These funnel plots represent a measure of study size on the vertical axis as a function of effect size on the horizontal axis. Large studies appear toward the top of the graph, and tend to cluster near the mean effect size. Smaller studies appear toward the bottom of the graph and (since there is more sampling variation in effect size estimates in the smaller studies) will be dispersed across a range of values. In the absence of publication bias, as is demonstrated in these funnel plots, the studies, represented by pale dotted circles, are distributed symmetrically about the combined effect size. The dashed diamond appearing below the x-axis represents the summary effect.

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Quantitative Data Synthesis

The comparative effect of CABG vs PCI on total mortality is shown in Figure 3. There was a significant 27% reduction in total mortality with CABG compared with PCI (I2 = 0%; RR, 0.73 [95% CI, 0.62-0.86]) (P < .001). There were numerically fewer myocardial infarctions in all of the included trials (Figure 4). On meta-analysis there was a significant 42% reduction in MI with CABG compared with PCI (I2 = 8.02%; RR, 0.58 [95% CI, 0.48-0.72]) (P < .001). There was a trend toward excess strokes with CABG (I2 = 24.9%; RR, 1.36 [95% CI, 0.99-1.86]), but this was not statistically significant (P = .06) (Figure 5). Repeat revascularizations (I2 = 75.6%; RR, 0.29 [95% CI, 0.21-0.41]) (P < .001) and major adverse cardiac and cerebrovascular events (MACCE) (I2 = 33.0%; RR, 0.61 [95% CI, 0.54-0.68]) (P < .001) were significantly reduced with CABG compared with PCI (Figure 6 and Figure 7).

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Figure 3.
Mortality According to Treatment Arm

Total number of patients, 6055 (I2 = 0% for the fixed effects model). CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RR, risk ratio; for expansion of all study name acronyms, see the cited references.

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Place holder to copy figure label and caption
Figure 4.
Myocardial Infarctions (MIs) According to Treatment Arm

Total number of patients, 5067 (I2 = 8.02% for the fixed effects model). CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RR, risk ratio; for expansion of all study name acronyms, see the cited references.

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Place holder to copy figure label and caption
Figure 5.
Strokes According to Treatment Arm

Total number of patients, 5067 (I2 = 24.9% for the fixed effects model). CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RR, risk ratio; for expansion of all study name acronyms, see the cited references.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.
Repeat Revascularizations According to Treatment Arm

Total number of patients, 6055 (I2 = 75.6% for the random effects model). CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RR, risk ratio; for expansion of all study name acronyms, see the cited references.

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Place holder to copy figure label and caption
Figure 7.
Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) According to Treatment Arm

Total number of patients, 4659 (I2 = 33.0% for the fixed effects model). CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RR, risk ratio; for expansion of all study name acronyms, see the cited references.

Graphic Jump Location

The number needed to treat was calculated using the obtained meta-analytic RRs and observed cumulative event rates in the PCI arms of the trials. Accordingly, CABG had to be preferred over PCI in 37 patients to save 1 life and in 26 patients to prevent 1 MI for the weighted average duration of follow-up of 4.1 years. The number needed to treat was 7 for repeat revascularizations and 10 for MACCE. The number needed to harm was 105 to cause 1 excess stroke with CABG.

Sensitivity Analysis

The magnitude of risk reduction in mortality was similar in trials limited to patients with diabetes and those not limited to patients with diabetes (P = .80 for heterogeneity) (Table 4). There was also no evidence of heterogeneity according to type of stent used (heterogeneity P = .56 for bare-metal vs drug-eluting stents). The findings of the meta-analysis remained stable with the one-study-out method ruling out the possibility of a single clinical trial dominating the results of the meta-analysis. There was also no statistically significant heterogeneity for risk reduction in MI according to whether trials were limited to patients with diabetes or the type of stent used (heterogeneity P > .10 for both). For the outcome of stroke, there was again no heterogeneity in results according to diabetes status or the type of stent used (heterogeneity P > .10 for both). For repeat revascularizations, there was significant heterogeneity according to the type of stent used (P = .002), with greater risk reduction in this outcome with CABG if bare-metal stents were used (RR, 0.27 [95% CI, 0.22-0.34] with bare-metal stents vs RR, 0.45 [95% CI, 0.36-0.56] with drug-eluting stents). There was no significant heterogeneity according to diabetes status for repeat revascularizations (P > .10).

Table Graphic Jump LocationTable 4.  Sensitivity Analyses for the Outcome of Mortality

One well-known clinical trial from South America did not meet the study inclusion criteria because the frequency of the use of arterial grafts in the CABG arm and the frequency of stent use in the PCI arm of this trial were too low.17 A sensitivity analysis adding this trial did not change the statistically significant reduction in mortality with CABG compared with PCI.

This meta-analysis of the contemporary era shows that in patients with multivessel CAD, CABG reduces long-term mortality by 27% compared with PCI, regardless of whether the study population is limited to patients with diabetes or not. Regarding major morbidity, a 42% risk reduction in MI was observed in patients randomized to CABG. There was a trend for excess strokes with CABG, probably related to an increase in periprocedural strokes. However, the absolute risk increase in stroke was small compared with the absolute risk reduction in mortality and MI, as demonstrated by the numbers needed to treat.

Although CAD is a leading cause of death worldwide, the optimal treatment strategy for this disease remains to be well defined. There have been important advances in nonsurgical therapies, including drug-eluting stents, newer anticoagulant-antiplatelet drug regimens, and aggressive lipid-lowering treatment, all of which have led to improved outcomes in nonsurgically treated patients with multivessel CAD. Additionally, improvements in surgical techniques including nearly universal arterial graft use and better postoperative care have rendered obsolete much of the surgical outcomes data from the clinical trials published before the turn of the century.1821 As PCI methods continue to evolve and surgical outcomes improve, it has become increasingly difficult to answer the ultimate question: “What is the best revascularization method for the patient with multivessel CAD?”

The more recent stent era trials comparing CABG with PCI have been underpowered for mortality and major morbidity, making the results difficult to interpret. This is partially because, unlike in previous eras, in the present era, the annual mortality of these patients is very low, under 2% to 3% in most studies. Consequently, the composite primary end point of MACCE was introduced to overcome the power limitation of these studies, and CABG almost always led to lower MACCE rates.7,9,11 However, MACCE is driven mainly by the soft end point of repeat revascularizations, which can be acceptable for many physicians and patients wishing to avoid cardiac surgery. This is especially important in the absence of evidence for significant improvement in mortality or major morbidity such as MI with CABG.35,710 For example, in the seminal first report of one of the landmark trials comparing CABG with PCI, mortality and MI rates were similar, while the stroke rate was higher in the CABG arm.9 As a result of this and other previous trials, as well as very large observational data sets reporting no mortality or morbidity benefit with CABG,22 practice patterns shifted toward stenting.13 To overcome the limitations of the underpowered studies, we performed this meta-analysis pooling data from multiple studies including a total of more than 6000 patients. Our analysis demonstrates that both long-term mortality and MIs are reduced significantly with CABG compared with PCI, regardless of whether drug-eluting or bare-metal stents are used. The validity of our findings are supported by a recent propensity-matched analysis of over 100 000 patients reporting superior survival and lower MI rates with multivessel CABG compared with multivessel PCI.23 It is notable that the results of the clinical trials included in this meta-analysis were homogeneous for all of the outcomes studied (ie, I2<40%) except for the outcome of repeat revascularization. For this outcome, the effect size was relatively smaller for the SYNTAX9 and FREEDOM16 trials (RR, >0.35 in both), where there was universal use of drug-eluting stents that reduce in-stent restenosis, compared with the other trials, which used bare-metal stents (RRs <0.30).

It has been long debated whether the presence of diabetes should dictate the revascularization method in patients with multivessel CAD. Traditionally, surgery has been preferred over PCI for this population. Evidence for this is largely based on the BARI study19 and comes from the plain balloon era. While the BARI study did not show an overall mortality benefit between the 2 revascularization methods, a post hoc subgroup analysis of diabetic patients showed a long-term mortality of 34.5% for balloon angioplasty and 19.4% for surgery (P = .03). Very recently, the results of the FREEDOM study16 enrolling only diabetic patients confirmed the mortality and morbidity benefit of CABG over PCI in this population. Therefore, it may be argued that the benefit of CABG over PCI is limited to patients with diabetes and that the mortality benefit of CABG seen in our meta-analysis is driven by diabetic patients. In this regard, among the trials included in our meta-analysis, 2 of them were limited to patients with diabetes alone, and 4 of the trials included primarily nondiabetic patients. On further analysis, there was no heterogeneity in reduction of mortality and MIs among the trials limited to and not limited to diabetic patients. The effect size for mortality reduction was very similar in trials enrolling only diabetic patients (25%) and the trials enrolling primarily nondiabetic patients (28%). While the FREEDOM trial is a landmark study that will consolidate the approach to revascularization in patients with diabetes and multivessel CAD, the vast majority of patients with multivessel disease are nondiabetic.24 Our results strongly suggest that CABG should be the revascularization method in patients with multivessel CAD, regardless of their diabetic status. However, it should be remembered that the included trials enrolled patients mostly with stable or unstable angina and excluded patients with acute MI. Therefore, our findings do not apply to the type of patients who were systematically excluded from these trials.

Our results must be interpreted in light of several limitations. This was necessarily a trial-level meta-analysis because we did not have access to individual patient-level data. Therefore, we were not able to perform subgroup analysis to see whether the superiority of CABG over PCI for mortality reduction was limited to certain subgroups (eg, those with intermediate to high SYNTAX scores or those with 3-vessel disease). Also, it may be argued that newer generation drug-eluting stents that are now commonly used during PCI such as the everolimus- or the zotarolimus-eluting stents were not tested in the trials included in this meta-analysis. In this context, it should be noted that the newer generation drug-eluting stents did not improve mortality compared with the sirolimus- or paclitaxel-eluting stents25,26 or the bare-metal stents27 in randomized controlled trials. Another argument could be that CABG may still not be the best approach for the management of patients with multivessel disease because our meta-analysis compared CABG only to PCI and not to medical therapy, and CABG may not be superior to medical therapy alone. In this context, there are 2 major contemporary randomized trials comparing CABG with medical therapy.6,28 The MASS II trial,6 which was also included in our meta-analysis, is one of these trials. This trial, primarily enrolling nondiabetic patients, had 3 arms, namely, CABG, PCI, and medical therapy arms. In MASS II, the 5-year mortality was 12.8% with CABG and 16.2% with medical therapy, although the difference was not statistically significant. Risk of acute MI was significantly reduced with CABG compared with medical therapy (RR, 0.41 [95% CI, 0.18-0.94]). The BARI 2D trial28 including patients with diabetes is the other relevant trial. In BARI 2D, within the CABG stratum, MIs were significantly less frequent in CABG plus intensive medical therapy vs intensive medical therapy alone groups (10.0% vs 17.6%) (P = .003), and the composite end point of death or MI (21.1% vs 29.2%) (P = .01) was also less frequent. These data, along with other data showing equivalence of stenting with medical therapy in stable multivessel coronary disease, suggests that CABG is not only superior to PCI but also to medical therapy for at least prevention of MI. Nevertheless, an appropriately sized randomized trial examining the effect of CABG vs medical therapy on total mortality in patients with preserved ejection fraction does not exist for the current era.

In patients with multivessel coronary disease, CABG does not only lead to a dramatic reduction in repeat revascularization and MACCE but also leads to a 27% reduction in long-term all-cause mortality and a 42% reduction in MIs compared with PCI. The benefits were not only observed in trials of diabetic patients but also in trials where the great majority of patients were nondiabetic. Use of bare-metal or drug-eluting stents did not alter the mortality benefit. Given these meaningful benefits, CABG should be the preferred revascularization method for most patients with multivessel coronary artery disease.

Corresponding Author: Ilke Sipahi, MD, FESC, Department of Cardiology, Acibadem University Medical School, Acibadem Maslak Hospital, Buyukdere Cad 40, 34457 Istanbul, Turkey (ilkesipahi@gmail.com).

Accepted for Publication: May 7, 2013.

Published Online: December 2, 2013. doi:10.1001/jamainternmed.2013.12844.

Authors Contributions: Dr Sipahi had full access to all the data used in the study and takes responsibility for the integrity of the data and accuracy of the analysis.

Study concept and design: Sipahi, Akay, Dagdelen, Alhan.

Acquisition of data: Sipahi, Akay.

Analysis and interpretation of data: Sipahi, Blitz, Alhan.

Drafting of the manuscript: Sipahi, Akay.

Critical revision of the manuscript for important intellectual content: Sipahi, Dagdelen, Blitz, Alhan.

Statistical analysis: Sipahi.

Administrative, technical, or material support: Sipahi.

Study supervision: Sipahi, Dagdelen, Alhan.

Conflict of Interest Disclosures: None reported.

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PubMed   |  Link to Article
Hlatky  MA, Boothroyd  DB, Baker  L,  et al.  Comparative effectiveness of multivessel coronary bypass surgery and multivessel percutaneous coronary intervention: a cohort study. Ann Intern Med. 2013;158(10):727-734.
PubMed   |  Link to Article
Shahian  DM, O’Brien  SM, Filardo  G,  et al; Society of Thoracic Surgeons Quality Measurement Task Force.  The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1--coronary artery bypass grafting surgery. Ann Thorac Surg. 2009;88(1)(Suppl):S2-S22.
PubMed   |  Link to Article
Wei  G, Fang  Y, Yaqi  R, Lin  C, Ningfu  W.  Clinical outcomes of zotarolimus-eluting stents versus the first generation sirolimus-eluting stents and paclitaxel-eluting stents: a meta-analysis of randomized trials. Int J Cardiol. 2012;157(1):152-156.
PubMed   |  Link to Article
de Waha  A, Cassese  S, Park  DW,  et al.  Everolimus-eluting versus sirolimus-eluting stents: an updated meta-analysis of randomized trials. Clin Res Cardiol. 2012;101(6):461-467.
PubMed   |  Link to Article
Eisenstein  EL, Leon  MB, Kandzari  DE,  et al; ENDEAVOR III Investigators.  Long-term clinical and economic analysis of the Endeavor zotarolimus-eluting stent versus the cypher sirolimus-eluting stent: 3-year results from the ENDEAVOR III trial (Randomized Controlled Trial of the Medtronic Endeavor Drug [ABT-578] Eluting Coronary Stent System Versus the Cypher Sirolimus-Eluting Coronary Stent System in De Novo Native Coronary Artery Lesions). JACC Cardiovasc Interv. 2009;2(12):1199-1207.
PubMed   |  Link to Article
Chaitman  BR, Hardison  RM, Adler  D,  et al; Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Study Group.  The Bypass Angioplasty Revascularization Investigation 2 Diabetes randomized trial of different treatment strategies in type 2 diabetes mellitus with stable ischemic heart disease: impact of treatment strategy on cardiac mortality and myocardial infarction. Circulation. 2009;120(25):2529-2540.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Flowchart of Trials Included in the Meta-analysis

For study acronym expansions, see the cited references.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Funnel Plots Examining Publication Bias for Mortality (A) and Myocardial Infarction (B)

Log risk ratios less than 0 favor coronary artery bypass grafting; those greater than 0 favor percutaneous coronary intervention. These funnel plots represent a measure of study size on the vertical axis as a function of effect size on the horizontal axis. Large studies appear toward the top of the graph, and tend to cluster near the mean effect size. Smaller studies appear toward the bottom of the graph and (since there is more sampling variation in effect size estimates in the smaller studies) will be dispersed across a range of values. In the absence of publication bias, as is demonstrated in these funnel plots, the studies, represented by pale dotted circles, are distributed symmetrically about the combined effect size. The dashed diamond appearing below the x-axis represents the summary effect.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Mortality According to Treatment Arm

Total number of patients, 6055 (I2 = 0% for the fixed effects model). CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RR, risk ratio; for expansion of all study name acronyms, see the cited references.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.
Myocardial Infarctions (MIs) According to Treatment Arm

Total number of patients, 5067 (I2 = 8.02% for the fixed effects model). CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RR, risk ratio; for expansion of all study name acronyms, see the cited references.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.
Strokes According to Treatment Arm

Total number of patients, 5067 (I2 = 24.9% for the fixed effects model). CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RR, risk ratio; for expansion of all study name acronyms, see the cited references.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.
Repeat Revascularizations According to Treatment Arm

Total number of patients, 6055 (I2 = 75.6% for the random effects model). CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RR, risk ratio; for expansion of all study name acronyms, see the cited references.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.
Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) According to Treatment Arm

Total number of patients, 4659 (I2 = 33.0% for the fixed effects model). CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RR, risk ratio; for expansion of all study name acronyms, see the cited references.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Characteristics of Randomized Trials of CABG vs PCI in Patients With Multivessel Disease Included in The Meta-analysis
Table Graphic Jump LocationTable 2.  Characteristics of Patients Enrolled in Randomized Trials of CABG vs PCI in Patients With Multivessel Disease Included in the Meta-analysisa
Table Graphic Jump LocationTable 3.  Disease Types in Patients Enrolled in Randomized Trials of CABG vs PCI in Patients With Multivessel Disease Included in the Meta-analysisa
Table Graphic Jump LocationTable 4.  Sensitivity Analyses for the Outcome of Mortality

References

Roger  VL, Go  AS, Lloyd-Jones  DM,  et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2-e220.
PubMed   |  Link to Article
SoS Investigators.  Coronary artery bypass surgery versus percutaneous coronary intervention with stent implantation in patients with multivessel coronary artery disease (the Stent or Surgery trial): a randomised controlled trial. Lancet. 2002;360(9338):965-970.
PubMed   |  Link to Article
Bravata  DM, Gienger  AL, McDonald  KM,  et al.  Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery. Ann Intern Med. 2007;147(10):703-716.
PubMed   |  Link to Article
Daemen  J, Boersma  E, Flather  M,  et al.  Long-term safety and efficacy of percutaneous coronary intervention with stenting and coronary artery bypass surgery for multivessel coronary artery disease: a meta-analysis with 5-year patient-level data from the ARTS, ERACI-II, MASS-II, and SoS trials. Circulation. 2008;118(11):1146-1154.
PubMed   |  Link to Article
Hlatky  MA, Boothroyd  DB, Bravata  DM,  et al.  Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet. 2009;373(9670):1190-1197.
PubMed   |  Link to Article
Hueb  W, Lopes  NH, Gersh  BJ,  et al.  Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation. 2007;115(9):1082-1089.
PubMed   |  Link to Article
Kapur  A, Hall  RJ, Malik  IS,  et al.  Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial. J Am Coll Cardiol. 2010;55(5):432-440.
PubMed   |  Link to Article
Mercado  N, Wijns  W, Serruys  PW,  et al.  One-year outcomes of coronary artery bypass graft surgery versus percutaneous coronary intervention with multiple stenting for multisystem disease: a meta-analysis of individual patient data from randomized clinical trials. J Thorac Cardiovasc Surg. 2005;130(2):512-519.
PubMed   |  Link to Article
Serruys  PW, Morice  MC, Kappetein  AP,  et al; SYNTAX Investigators.  Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961-972.
PubMed   |  Link to Article
Serruys  PW, Ong  AT, van Herwerden  LA,  et al.  Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial. J Am Coll Cardiol. 2005;46(4):575-581.
PubMed   |  Link to Article
Serruys  PW, Unger  F, Sousa  JE,  et al; Arterial Revascularization Therapies Study Group.  Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med. 2001;344(15):1117-1124.
PubMed   |  Link to Article
Kappetein  AP, Feldman  TE, Mack  MJ,  et al.  Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J. 2011;32(17):2125-2134.
PubMed   |  Link to Article
Riley  RF, Don  CW, Powell  W, Maynard  C, Dean  LS.  Trends in coronary revascularization in the United States from 2001 to 2009: recent declines in percutaneous coronary intervention volumes. Circ Cardiovasc Qual Outcomes. 2011;4(2):193-197.
PubMed   |  Link to Article
Begg  CB, Mazumdar  M.  Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088-1101.
PubMed   |  Link to Article
Booth  J, Clayton  T, Pepper  J,  et al; SoS Investigators.  Randomized, controlled trial of coronary artery bypass surgery versus percutaneous coronary intervention in patients with multivessel coronary artery disease: six-year follow-up from the Stent or Surgery Trial (SoS). Circulation. 2008;118(4):381-388.
PubMed   |  Link to Article
Farkouh  ME, Domanski  M, Sleeper  LA,  et al; FREEDOM Trial Investigators.  Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367(25):2375-2384.
PubMed   |  Link to Article
Rodriguez  AE, Baldi  J, Fernández Pereira  C,  et al; ERACI II Investigators.  Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II). J Am Coll Cardiol. 2005;46(4):582-588.
PubMed   |  Link to Article
 First-year results of CABRI (Coronary Angioplasty versus Bypass Revascularisation Investigation): CABRI Trial Participants. Lancet. 1995;346(8984):1179-1184.
PubMed   |  Link to Article
The Bypass Angioplasty Revascularization Investigation (BARI) Investigators.  Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med. 1996;335(4):217-225.
PubMed   |  Link to Article
Henderson  RA, Pocock  SJ, Sharp  SJ,  et al.  Long-term results of RITA-1 trial: clinical and cost comparisons of coronary angioplasty and coronary-artery bypass grafting. Randomised Intervention Treatment of Angina. Lancet. 1998;352(9138):1419-1425.
PubMed   |  Link to Article
King  SB  III, Lembo  NJ, Weintraub  WS,  et al.  A randomized trial comparing coronary angioplasty with coronary bypass surgery. Emory Angioplasty versus Surgery Trial (EAST). N Engl J Med. 1994;331(16):1044-1050.
PubMed   |  Link to Article
Benedetto  U, Melina  G, Angeloni  E,  et al.  Coronary artery bypass grafting versus drug-eluting stents in multivessel coronary disease. A meta-analysis on 24,268 patients. Eur J Cardiothorac Surg. 2009;36(4):611-615.
PubMed   |  Link to Article
Hlatky  MA, Boothroyd  DB, Baker  L,  et al.  Comparative effectiveness of multivessel coronary bypass surgery and multivessel percutaneous coronary intervention: a cohort study. Ann Intern Med. 2013;158(10):727-734.
PubMed   |  Link to Article
Shahian  DM, O’Brien  SM, Filardo  G,  et al; Society of Thoracic Surgeons Quality Measurement Task Force.  The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1--coronary artery bypass grafting surgery. Ann Thorac Surg. 2009;88(1)(Suppl):S2-S22.
PubMed   |  Link to Article
Wei  G, Fang  Y, Yaqi  R, Lin  C, Ningfu  W.  Clinical outcomes of zotarolimus-eluting stents versus the first generation sirolimus-eluting stents and paclitaxel-eluting stents: a meta-analysis of randomized trials. Int J Cardiol. 2012;157(1):152-156.
PubMed   |  Link to Article
de Waha  A, Cassese  S, Park  DW,  et al.  Everolimus-eluting versus sirolimus-eluting stents: an updated meta-analysis of randomized trials. Clin Res Cardiol. 2012;101(6):461-467.
PubMed   |  Link to Article
Eisenstein  EL, Leon  MB, Kandzari  DE,  et al; ENDEAVOR III Investigators.  Long-term clinical and economic analysis of the Endeavor zotarolimus-eluting stent versus the cypher sirolimus-eluting stent: 3-year results from the ENDEAVOR III trial (Randomized Controlled Trial of the Medtronic Endeavor Drug [ABT-578] Eluting Coronary Stent System Versus the Cypher Sirolimus-Eluting Coronary Stent System in De Novo Native Coronary Artery Lesions). JACC Cardiovasc Interv. 2009;2(12):1199-1207.
PubMed   |  Link to Article
Chaitman  BR, Hardison  RM, Adler  D,  et al; Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Study Group.  The Bypass Angioplasty Revascularization Investigation 2 Diabetes randomized trial of different treatment strategies in type 2 diabetes mellitus with stable ischemic heart disease: impact of treatment strategy on cardiac mortality and myocardial infarction. Circulation. 2009;120(25):2529-2540.
PubMed   |  Link to Article

Correspondence

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Add new trial, get new results
Posted on December 30, 2013
You-Dong Wan, Tong-Wen Sun, Quan-Cheng Kan
Department of Integrated ICU, the First Affiliated Hospital of Zhengzhou University
Conflict of Interest: Funding/Support: This study was supported by the National Natural Science Foundation of China (Grant No. 81370364), Innovative investigators project grant from the Health Bureau of Henan Province, Program Grant for Science & Technology Innovation Talents in Universities of Henan Province (2012HASTIT001), Henan Provincial Science and Technology Achievement Transformation Project(122102310581), Henan Province of Medical Scientific Province & Ministry Research Project(201301005), Henan Province of Medical Scientific Research Project(201203027),China.
Ilke Sipahi and colleagues1 have done a fantastic job in pooling the data from trials of coronary artery bypass grafting (CABG) versus percutaneous coronary interventions(PCI) for multivessel disease. However, it may not be appropriate to pool the included studies. At first, the average follow-up duration of trials included is 1 to 6 years. However, this range was too large to evaluate the long-term results. According to the data from the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, the one-year mortality2 of PCI was 4.4% and the five-year mortality2 was 13.9%, which was really different. In addition, previous meta-analysis3 found CABG could provide significant survival advantage at both five and eight years, but no significant advantage at one, three years. Meta analysis of these data without layering may result in unadjusted inner-heterogeneity. Secondly, Ilke Sipahi and colleagues1 also included trials with only diabetic or mixed population, though sensitivity analyses show no difference with or without diabetic, but this subgroup analysis was limited by its poor amount of trials. A meta-analysis of individual patient data4 from ten randomised trials suggested that diabetes and age modify the effect of CABG compared with PCI on the survival of patients with multivessel coronary disease, so it is unclear why these two meta analysis get inconsistent results. Ilke Sipahi and colleagues1 make a systematic literature search through December 2012, however, the SYNTAX trial, released their five year results on February 23, 2013. Thus, we included that trial2 and other studies with their 5- years follow-up results, excluding trials only focus on patients with diabetes, found that PCI with stent had no difference in all-cause mortality compared with CABG5 (risk ratio [RR], 1.13,[95%CI, 0.88 - 1.44]). This result was surpring, and it may be interesting to expore the reasons.References1. Sipahi I, Akay MH, Dagdelen S, et al. Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention and Long-term Mortality and Morbidity in Multivessel Disease: Meta-analysis of Randomized Clinical Trials of the Arterial Grafting and Stenting Era. JAMA Intern Med.2013.2. Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet.2013;381(9867):629-638.3. Hoffman SN, Tenbrook JA, Wolf MP, et al. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes. J Am Coll Cardiol.2003;41(8):1293-1304.4. Hlatky MA, Boothroyd DB, Bravata DM, et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet.2009;373(9670):1190-1197.5. Wan YD, Sun TW, Kan QC, et al. Long-term outcomes of percutaneous coronary intervention with stenting and coronary artery bypass graft surgery - a meta-analysis. Int J Cardiol.2013;168(6):e161-e164.
Add new trial, get new results
Posted on December 30, 2013
You-Dong Wan, Tong-Wen Sun, Quan-Cheng Kan
Department of Integrated ICU, the First Affiliated Hospital of Zhengzhou University
Conflict of Interest: Funding/Support: This study was supported by the National Natural Science Foundation of China (Grant No. 81370364), Innovative investigators project grant from the Health Bureau of Henan Province, Program Grant for Science & Technology Innovation Talents in Universities of Henan Province (2012HASTIT001), Henan Provincial Science and Technology Achievement Transformation Project(122102310581), Henan Province of Medical Scientific Province & Ministry Research Project(201301005), Henan Province of Medical Scientific Research Project(201203027),China.
Ilke Sipahi and colleagues1 have done a fantastic job in pooling the data from trials of coronary artery bypass grafting (CABG) versus percutaneous coronary interventions(PCI) for multivessel disease. However, it may not be appropriate to pool the included studies. At first, the average follow-up duration of trials included is 1 to 6 years. However, this range was too large to evaluate the long-term results. According to the data from the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, the one-year mortality2 of PCI was 4.4% and the five-year mortality2 was 13.9%, which was really different. In addition, previous meta-analysis3 found CABG could provide significant survival advantage at both five and eight years, but no significant advantage at one, three years. Meta analysis of these data without layering may result in unadjusted inner-heterogeneity. Secondly, Ilke Sipahi and colleagues1 also included trials with only diabetic or mixed population, though sensitivity analyses show no difference with or without diabetic, but this subgroup analysis was limited by its poor amount of trials. A meta-analysis of individual patient data4 from ten randomised trials suggested that diabetes and age modify the effect of CABG compared with PCI on the survival of patients with multivessel coronary disease, so it is unclear why these two meta analysis get inconsistent results. Ilke Sipahi and colleagues1 make a systematic literature search through December 2012, however, the SYNTAX trial, released their five year results on February 23, 2013. Thus, we included that trial2 and other studies with their 5- years follow-up results, excluding trials only focus on patients with diabetes, found that PCI with stent had no difference in all-cause mortality compared with CABG5 (risk ratio [RR], 1.13,[95%CI, 0.88 - 1.44]). This result was surpring, and it may be interesting to expore the reasons.References1. Sipahi I, Akay MH, Dagdelen S, et al. Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention and Long-term Mortality and Morbidity in Multivessel Disease: Meta-analysis of Randomized Clinical Trials of the Arterial Grafting and Stenting Era. JAMA Intern Med.2013.2. Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet.2013;381(9867):629-638.3. Hoffman SN, Tenbrook JA, Wolf MP, et al. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes. J Am Coll Cardiol.2003;41(8):1293-1304.4. Hlatky MA, Boothroyd DB, Bravata DM, et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet.2009;373(9670):1190-1197.5. Wan YD, Sun TW, Kan QC, et al. Long-term outcomes of percutaneous coronary intervention with stenting and coronary artery bypass graft surgery - a meta-analysis. Int J Cardiol.2013;168(6):e161-e164.Corresponding to:Tong-Wen Sun, MD, PhD, Department of Integrated Intensive Care Unit, the First Affiliated Hospital, Zhengzhou University, E-mail: suntongwen@163.com.
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