Bypass Surgery or Stents?

Bypass Surgery for Multivessel CAD Reaffirmed in Newer Data

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Surgeons fire back at downgrading of CABG in recent guidelines

The recently weakened endorsement of coronary artery bypass grafting (CABG) for multivessel disease is not supported by contemporary real-world data, heart surgeons argued.

Based on over 100,000 Medicare beneficiaries presenting with acute coronary syndrome (ACS) who underwent revascularization, risk-adjusted rates of death, myocardial infarction (MI), heart failure, acute kidney injury, and readmissions at 30 days after discharge all favored CABG over multivessel percutaneous coronary intervention (PCI).

Moreover, CABG was associated with improved 3-year survival (HR 0.448, 95% CI 0.437-0.458) and the composite endpoint of reintervention, MI, and death (HR 0.476, 95% CI 0.46-0.493). Longitudinal outcomes favored CABG in key subgroups of patients older than 75 years and those with baseline diabetes, heart failure, or non-ST-segment elevation MI (NSTEMI).

Only stroke readmission rates did not significantly favor CABG over PCI after risk adjustment of longitudinal outcomes, reported J. Hunter Mehaffey, MD, MSc, a cardiac surgeon at West Virginia University in Morgantown, during this year’s meeting of the Society of Thoracic Surgeons (STS)opens in a new tab or window.

“These longitudinal data support the superiority of CABG compared to PCI and may have current and future policy and practice implications,” Mehaffey said, adding that he wished to “take back the narrative about bypass surgery to make sure patients are getting optimal treatment.”

Fellow surgeon Joseph Sabik, III, MD, of University Hospitals Cleveland Medical Center, called this an important study with “impressive” findings that should prompt reevaluation of the recent controversial guideline change that had not been endorsed by surgeon societies — namely the STS and the American Association for Thoracic Surgery.

The controversy erupted in 2021 when American guidelines downgraded CABG from class I to class IIbopens in a new tab or window, on par with PCI, in multivessel disease and normal left ventricular ejection fraction in stable ischemic heart disease. This change was attributed to the guideline writers considering only the most recent studies from the prior 5 years — meaning the downgrade of CABG was based largely on the ISCHEMIA trial that had found an initial invasive approach to be no better than medical therapy aloneopens in a new tab or window in stable coronary artery disease.

Yet ISCHEMIA was not representative of patients undergoing CABG and failed to capture those with multivessel disease in particular, Mehaffey argued.

Sabik, speaking as the STS session discussant, pointed out that the controversy is in stable ischemic disease, whereas the study by Mehaffey’s group covers an ACS population. Nevertheless, the results at least raise the question of whether CABG should be the preferred therapy for all patients with ACS, Sabik said.

Mehaffey acknowledged the disparate patient populations being discussed but warned of guideline creep as “many clinical providers do not read the fine print,” only reviewing the executive summary or a lay media report. He reminded the audience that his results persisted in NSTEMI.

Sabik also cautioned that the improved clinical outcomes after CABG surgery came at the cost of greater in-hospital morbidity: In-hospital outcome of death favored CABG, whereas PCI was associated with less bleeding, stroke, acute kidney injury, and acute renal failure.

Moreover, CABG was associated with significantly higher hospital cost compared with PCI ($57,189 vs $36,342, P< 0.001) and longer total hospital stays (11.9 days vs 5.8 days, P<0.001), the study authors found.

Aiming to give guideline committees the contemporary data that they want, Mehaffey and colleagues had limited their analysis to Medicare beneficiaries presenting from January 2018 to December 2020.

The observational study relied on a database of Centers for Medicare & Medicaid Services inpatient claims. Participants were people who underwent CABG (n=51,389) or multivessel PCI (n=52,738), excluding those with a history of concomitant valvular procedures, prior CABG, and heart transplantation.

Compared with the PCI arm, CABG recipients were younger (72.9 vs 75.2 years, P<0.001) but tended to have a higher Elixhauser Comorbidity Index (5.0 vs 4.2, P<0.001), and a higher likelihood of diabetes (48.5% vs 42.2%, P<0.001). The CABG cohort also had lower rates of ST elevation MI at presentation (14.4% vs 29.0%, P<0.001).

The groups were relatively well-balanced after matching by inverse probability of treatment weighting propensity scores.

Nevertheless, the observational analysis remained subject to potential confounding and biases inherent in its nonrandomized design.

“The findings of our study were very convincing,” Mehaffey maintained in a press releaseopens in a new tab or window. “The singular message to the public is that the optimal treatment for multivessel coronary artery disease — to improve not only long-term survival but also lower your risk of complications — is coronary artery bypass surgery.”

“These contemporary real-world data support prior existing trials highlighting the benefits of CABG in multivessel coronary artery disease, urging a re-evaluation of recent guidelines,” he said.

For Multiple Heart Blockages, Bypass Surgery or Stents?

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Study Compares Pain, Quality of Life After Drug-Coated Stents or Coronary Artery Bypass Surgery

For patients who have several blocked arteries around their heart, the gold standard treatment has long been coronary artery bypass surgery.
Now a large clinical trial suggests that drug-coated stents, springy lattice tubes used to prop open clogged arteries, may also work well in patients with multiple blockages. And in some patients, the stents produce equally good results with faster recovery times.

The caveats, experts say, are that people with daily or weekly chest pain from advanced coronary artery disease will probably experience slightly better relief from bypass surgery compared to stenting; but they can also count on waiting to get the full benefit of that procedure weeks to months longer than people who get stents.
Experts say the study, which is published in The New England Journal of Medicine, brings to light important trade-offs that people with complex coronary artery disease need to weigh before making a decision between the two procedures.

“I think the message here, therefore, is not a simple one — that there’s a clear winner — but that patients will need to choose based on their own priorities and values,” says study researcher David J. Cohen, MD, a cardiologist at St. Luke’s Mid America Heart Institute in Kansas City, Mo.
Independent experts agree.
“If you take the 50,000-mile view, it looks like these procedures got about the same results,” says A. Marc Gillinov, MD, cardiac surgeon at the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic, in Ohio. “But if you really dig down and look at the clinical circumstances going in, you’ll see there are important differences. So the real value in this study is that it can help patients and doctors make informed decisions on an individual basis.”

A Visual Guide to Heart Disease
Comparing the Effectiveness of Stents vs. Bypass

For the study, researchers at 85 medical centers around the world randomly assigned 1,800 patients with at least three clogged arteries around their hearts, or alternatively, a clogged left main coronary artery — the vessel that carries the lion’s share of blood to the heart’s primary pumping chamber — to one of two treatments: coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI).
In CABG, surgeons typically saw through the breast bone and open the rib cage, a procedure that, in and of itself, requires significant downtime for recovery. Doctors usually also need to make incisions in other parts of the body, often the legs, to harvest healthy vessels that can be used to bypass blockages.
PCI, a catheter is threaded through an artery in the groin up to the heart, where a doctor uses a video monitor and radioactive dye to locate the blockages within arteries. The doctor then inflates a balloon to compress the buildup against the artery walls and places a stent to hold the spot open.

The stents in this trial were coated with the drug paclitaxel, which is thought to help prevent the formation of scar tissue around the site of stent implantation, a problem called restenosis.
Before any procedure was performed, an interventional cardiologist and a cardiac surgeon consulted together on each case. If there was mutual agreement that the blocked vessels might be effectively opened using either procedure, the patient was cleared to enter the study.

Before patients were assigned to one procedure or the other, doctors asked patients questions about how often and how strongly they’d been feeling angina, or chest pain, their physical limitations and general quality of life. Based upon the answers, patients were scored on a scale of 1 to 100, with higher scores indicating fewer symptoms and better health status.

Those questions were asked again one month, six months, and 12 months after their procedures.

A disease severity score was also determined at study entry for each patient. This score is dependent upon the degree and extent of blockages as demonstrated on the initial angiogram, with higher scores indicating more complex disease. For subsequent analysis purposes, the patients in the study were divided into three subgroups depending upon their disease severity scores (0 to 22, 23 to 32, and 33 to 83).

In all, 903 patients received stents, while 897 had bypass surgery. In both cases, doctors tried to open all the arteries that were at least 50% blocked.

In the first phase of the study, which was published in 2009, researchers looked primarily at the risk of having a major event, like a heart attack, stroke, or having to reopen an artery that had clogged a second time. After one year, there were about 5% fewer total events in the bypass group compared to the stent group, 12.4% compared to 17.8% respectively.

More patients needed to have clogged arteries reopened in the PCI group than in the CABG group, 13.9% vs. 5.9%, respectively.

After one year, the rate of heart attack or death was similar between the two groups, while stroke was more likely to occur in the bypass group (2.2%) compared to the stent group (0.6%).
Looking at Quality of Life

When researchers looked at angina and quality of life in study participants, overall, both groups fared well. In fact, slightly more than half of people in both groups reported substantial improvement in angina as early as one month after their procedures.

But when investigators looked at those measures across various time points, and in people with more and less severe disease, differences emerged.

As was expected, people who got stents generally felt better faster, compared to the group that had bypass surgery, probably because there was less healing time required after the less invasive procedure.

But by six and 12 months after their procedures, both groups reported nearly equal improvements in physical functioning, pain, vitality, and social and mental health.

And after six months, researchers say people that went into the study with daily or weekly chest pain experienced greater relief after CABG than did those who got PCI.

“Angina relief at six months and a year was better with bypass surgery, though the difference was small,” says Cohen. “But there were clear differences in the early quality of life on a wide range of dimensions that clearly favored PCI, but those benefits were transient,” he says.

The study was sponsored by Boston Scientific, which produces paclitaxel-coated stents.

source: webMD