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Jan B. Wade · #1 (**permalink**) 05-26-2005, 04:15 AM

Study Gives Survival Edge to CABG Over Stenting

By Peggy Peck, Senior Editor, MedPage Today

Observational Study

Review
ALBANY, N.Y., May 25-Compared with stenting, coronary artery bypass graft surgery increased long term survival in patients with two or more diseased arteries, researchers reported Wednesday.

For patients with three-vessel coronary artery disease, CABG increased three-year survival by 36%, and for those with two vessel disease CABG increased survival by 24% compared to stenting, according to a report in the May 26 issue of the New England Journal of Medicine.

Using data from New York's cardiac registries, researchers compared outcome up to three years in 37,212 CABG patients and 22,102 stent patients. After adjusting for severity of illness, "CABG was associated with a significantly higher likelihood of survival in all anatomical groups," Edward L. Hannan, Ph.D., of the State University of New York at Albany and colleagues wrote.

They added that revascularization rates were also significantly higher (P <0.001) after stenting than after CABG. They found that 7.8% of stent patients will eventually require CABG and 27.3% will require another trip to the catheter lab for additional percutaneous coronary interventions. Among CABG patients just 0.3% required a second bypass procedure and 4.6% required revascularization with percutaneous coronary interventions.

Stenting, however, had a significantly lower in hospital mortality than CABG -- 0.68% or 150 deaths in the stenting group versus 1.5% or 650 deaths in the CABG group (P <0.001).

In an editorial that accompanied the study, Bernard J. Gersh, M.B., Ch.B., D.Phil., and Robert L. Frye, M.D., of the Mayo Clinic pointed out that many previous studies have "suggested that survival is not compromised by an initial strategy of percutaneous coronary interventions, except in patients with diabetes. Therefore, the implications of this study are profound and suggest that things are not as clear-cut as originally thought."

A shortcoming of the study, according to both the researchers and the editorial writers, is that it compares approaches that have changed significantly since the time of treatment -- 1997 to 2000. In the intervening years, CABG surgery has evolved so that today many procedures are done without use of cardiopulmonary bypass and today's stents of choice are drug eluting stents that have significantly reduced the risk of restenosis.

Additionally, the authors pointed out that the findings are based on observational data.

More definitive evidence is anticipated from the on-going Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) study, a 1,500-patient National Heart, Lung and Blood Institute trial that compares drug eluting stents plus ReoPro (abciximab) to CABG.

The researchers concluded that factors such as life-expectancy and "attitudes about the relative merits of short-term and long-term risk" should be factored into the choice and treatment and thus may make stenting a preferred option even for patients in an "anatomical group for which CABG has a significantly higher risk-adjusted long-term survival."

Patients receiving stents were slightly younger, median age 65 versus 67 (P <0.001), and the median ejection fraction was 53% in the stent group versus 50% in the CABG group. Stent patients were more likely to have had a myocardial infarction in the week before procedure (22.8%) versus the CABG patients (16.3%) and that was also significant (P <0.001). In general CABG patients had more comorbidities including history of stroke, congestive heart failure, diabetes, and COPD (P <0.001 for all).