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Yesterday, results from a late-breaking registry study, presented by Professor Elmir Omerovic (Sahlgrenska University Hospital, Gothenburg, Sweden), provided strong support for the superiority of coronary artery bypass graft (CABG) over percutaneous coronary intervention (PCI) in the revascularisation of patients with stable heart failure due to multivessel coronary disease (LBT31).
Prof. Omerovic explains that there are currently few data to guide the choice of revascularisation technique for patients with stable heart failure and ischaemic heart disease. European1 and US2 guidelines recommend CABG over PCI but conclusive data are lacking. While the randomised STICH trial (which forms much of the basis of guideline recommendations) established CABG as the preferred approach compared with medical therapy alone,3 there are no randomised trials comparing PCI with medical therapy.
Sweden is unique among countries in having comprehensive and high-quality cardiovascular registry data, says Prof. Omerovic, allowing a relatively large number of patients to be investigated over a long follow-up period. In the study reported, data from the prospective Swedish Coronary Angiography and Angioplasty Registry (SCAAR) were used to compare PCI (n=1,409) and CABG (n=1,100) in patients with heart failure with reduced ejection fraction and multivessel disease. Patients treated between 2000 and 2018 were included and the primary endpoint was all-cause mortality. The median follow-up time was 1,429 days.
There were 1,010 deaths (40.5%) and the risk of death was significantly lower with CABG compared with PCI (hazard ratio 0.79; 95% confidence intervals 0.68–0.93; p=0.005).
Significant interactions between CABG and both women (hazard ratio [HR] 0.67) and diabetes (HR 0.74), require confirmation. “The results almost replicate the findings from the STICH trial in supporting CABG as the preferred approach in these patients,” says Prof. Omerovic. The validity of the findings are reinforced by the size of the population, the number of events and adjustment for confounding factors, which give the results considerable statistical power.
According to Prof. Omerovic, not only do the findings give weight to current guideline recommendations, they will also be invaluable in helping to design a randomised clinical trial that is being planned to provide the definitive answer. For example, the all-cause mortality difference between CABG and PCI only starts to become apparent after three years. Therefore, any randomised trial should have a follow-up period of at least five years. Concluding, Prof. Omerovic says, “We know that, contrary to guideline recommendations, PCI is used more and more frequently in this patient population. This study provides important data to demonstrate that CABG should, at least for now, remain the preferred approach.”
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