For patients with 3-vessel disease or left main disease, is percutaneous coronary intervention with a drug-eluting stent noninferior to coronary artery bypass graft?

For patients with left main disease, percutaneous coronary intervention (PCI) with a drug-eluting stent and coronary artery bypass graft (CABG) had similar all-cause mortality rates at 10 years. For those with 3-vessel disease, however, CABG is associated with lower 10-year mortality (21% vs 28%; number needed to treat = 14). (LOE = 1b)

Thuijs DJ, Kappetein AP, Serruys PW, et al. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial. Lancet 2019;394(10206):1325-1334.  [PMID:31488373]

Randomized controlled trial (nonblinded)

Government

Concealed

Outpatient (any)

This is the 10-year follow-up to a trial that initially randomized 1800 patients with 3-vessel coronary artery disease or left main disease to receive either PCI with a drug-eluting stent or CABG. Groups were balanced at the beginning of the trial and analysis was by intention to treat. The average age of participants was 65 years, 25% had diabetes, 33% had a previous myocardial infarction, and 9% had a previous stroke or transient ischemic attack. Left main disease was present in 40% and 3-vessel disease in 60% of the patients. The primary outcome was all-cause mortality, ascertained primarily from national death registries. Median follow-up was 11.2 years. At 10 years, 27% of patients in the PCI group had died compared with 24% in the CABG group (hazard ratio [HR] 1.17; 95% CI 0.97 - 1.41). Analyzing the period from 5 years to 10 years separately, the authors again found no significant difference (13% for PCI vs 12% for CABG). There was a difference between groups based on their initial lesion. In those with 3-vessel disease all-cause mortality was significantly higher in the PCI group (28% vs 21%; HR 1.41; 1.10 - 1.80), while there was no difference in mortality for those with left main disease (26% for PCI vs 28% for CABG). Results were similar for patients with and without diabetes.