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CABG not PCI for most people with complex coronary artery disease

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1289 (Published 27 February 2013) Cite this as: BMJ 2013;346:f1289

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Coronary artery bypass grafting (CABG) surgery is a better option than percutaneous coronary intervention (PCI) for most patients with stable but complex coronary artery disease, according to the final report from a landmark head to head trial. During five years of follow-up, adults assigned to surgery had significantly fewer major cardiac or cerebrovascular events than adults treated with PCI and drug eluting stents (26.9% v 37.3%; P<0.0001). All participants had disease in the left main coronary artery, three other vessels, or both. CABG looked particularly effective for adults with the most severe disease, reducing death from all causes (11.4% v 19.2%; P=0.005), myocardial infarctions, and revascularisations, as well as the composite outcome.

The authors estimate that about two thirds of patients with complex coronary artery disease should undergo CABG. But the minority with the least complex disease may still have a choice. Outcomes after CABG and PCI were not significantly different (rate of major coronary or cerebrovascular events 28.6% after CABG v 32.1% after PCI; P=0.43) in this subgroup, defined using the recommended SYNTAX score of anatomical complexity. The trial was sponsored by the manufacturers of paclitaxel eluting stents.

In a linked study, other researchers propose a SYNTAX mark II that adds one extra anatomical feature (presence or absence of disease in the left main artery) and six clinical features (age, sex, creatinine clearance, ejection fraction, chronic obstructive pulmonary disease, and peripheral vascular disease). The new version was better at predicting four year mortality after CABG or PCI and may prove useful after external validation, says a linked comment (p 605).

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Cite this as: BMJ 2013;346:f1289