Comparative effectiveness of revascularization strategies for early coronary artery disease: A multicenter analysis

Michael P. Robich, Maine Medical Partners, Maine Medical Center, Portland, Me. Electronic address: MRobich@mmc.org.
Bruce J. Leavitt, Department of Cardiothoracic Surgery, Heart and Vascular, University of Vermont Medical Center, Burlington, Vt.
Thomas J. Ryan, Maine Medical Partners, Maine Medical Center, Portland, Me.
Benjamin M. Westbrook, New England Heart and Vascular Institute, Catholic Medical Center, Manchester, NH.
David J. Malenka, Departments of Medicine and Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Daniel J. Gelb, Departments of Medicine and Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Cathy S. Ross, Departments of Medicine and Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Alan Wiseman, EMMC Heart Care, Eastern Maine Medical Center, Bangor, Me.
Patrick Magnus, Center for Cardiac Care, Concord Hospital, Concord, NH.
Yi-Ling Huang, Departments of Medicine and Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Anthony W. DiScipio, Departments of Medicine and Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Alexander Iribarne, Departments of Medicine and Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Abstract

OBJECTIVES: The goal of this analysis was to examine the comparative effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention among patients aged less than 60 years. METHODS: We performed a multicenter, retrospective analysis of all cardiac revascularization procedures from 2005 to 2015 among 7 medical centers. Inclusion criteria were age less than 60 years and 70% stenosis or greater in 1 or more major coronary artery distribution. Exclusion criteria were left main 50% or greater, ST-elevation myocardial infarction, emergency status, and prior revascularization procedure. After applying inclusion and exclusion criteria, the final study cohort included 1945 patients who underwent cardiac surgery and 2938 patients who underwent percutaneous coronary intervention. The primary end point was all-cause mortality stratified by revascularization strategy. Secondary end points included stroke, repeat revascularization, and 30-day mortality. We used inverse probability weighting to balance differences among the groups. RESULTS: After adjustment, there was no significant difference in 30-day mortality (surgery: 0.8%; percutaneous coronary intervention: 0.7%, P = .86) for patients with multivessel disease. Patients undergoing surgery had a higher risk of stroke (1.3% [n = 25] vs 0.07% [n = 2], P < .001). Overall, surgery was associated with superior 10-year survival compared with percutaneous coronary intervention (hazard ratio, 0.71; 95% confidence interval, 0.57-0.88; P = .002). Repeat procedures occurred in 13.4% (n = 270) of the surgery group and 36.4% (n = 1068) of the percutaneous coronary intervention group, with both groups mostly undergoing percutaneous coronary intervention as their second operation. Accounting for death as a competing risk, at 10 years, surgery resulted in a lower cumulative incidence of repeat revascularization compared with percutaneous coronary intervention (subdistribution hazard ratio, 0.34; 95% confidence interval, 0.28-0.40; P < .001). CONCLUSIONS: Among patients aged less than 60 years with 2-vessel disease that includes the left anterior descending or 3-vessel coronary artery disease, surgery was associated with greater long-term survival and decreased risk of repeat revascularization.