NEJM article on effectiveness of CABG vs PCI

[Laskpau]

What are your thoughts?

http://doi.org/hr5

"CONCLUSIONS
In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI."

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[jdh71]

What are your thoughts?

http://doi.org/hr5

"CONCLUSIONS
In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI."

What was interesting to me was that there is no mention anywhere in the paper about the statistical significance of the observed "survival benefit". They make sure you know there is no "statistical significant" difference in survival at 1 year, and then when we get to the 4 year numbers, all they state is that there is a survival benefit - the raw number of those surviving by a percentage at 4 years is higher, but no mention if this difference was even statistically significant, because if not statistically significant then what's their point?

 

[DoctwoB]

What was interesting to me was that there is no mention anywhere in the paper about the statistical significance of the observed "survival benefit". They make sure you know there is no "statistical significant" difference in survival at 1 year, and then when we get to the 4 year numbers, all they state is that there is a survival benefit - the raw number of those surviving by a percentage at 4 years is higher, but no mention if this difference was even statistically significant, because if not statistically significant then what's their point?

Not sure what you're worried about.

"At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82)."

95% CI not including 1 means p<.05, and in this case, is probably <.01 based on the narrow CI. Also just look at the numbers. A 4% absolute mortality benefit w/ about 100k patients in each arm is way more then enough for significance.

These are pretty astounding results IMO, and I'm surprised more hasn't been made out of them. We'll see if cardiologists are happy giving many of their patients back to the CT surgeons.

 

[MD2b06]

The study is observational in nature. Not a randomized control trial. Limited by selection bias. Stent technology has improved leaps and bounds since 2004. 6% of the patients in the PCI arm didn't even receive stents. Personally I'll wait for the EXCEL trial.

 

[Chakrabs]

I don't see how this is going to change therapy that much. At pretty much every hospital I've rotated at, its been standard practice for the cardiologists to refer multi-vessel disease patients to the CT Surgeons.

 

[Trifling Jester]

I don't see how this is going to change therapy that much. At pretty much every hospital I've rotated at, its been standard practice for the cardiologists to refer multi-vessel disease patients to the CT Surgeons.

Depends on the individual interventionalist where I'm at. With some non-diabetics they look at specific lesion characteristics, not necessarily looking at an exact syntax score per se, but that general idea. Then do staged PCI.

 

[dragonfly99]

The study is observational in nature. Not a randomized control trial. Limited by selection bias. Stent technology has improved leaps and bounds since 2004. 6% of the patients in the PCI arm didn't even receive stents. Personally I'll wait for the EXCEL trial.

This is an OBSERVATIONAL STUDY, not randomized controlled trial. One might hypothesize that for various reasons, patients who eyeball poorly for any reason (such as general frailty, COPD, obesity, socially bad/schizo, etc.) are less likely to go for a CABG. It's sometimes easier to do a PCI (technically and in terms of getting a patient and family to agree to something). Also, the surgeons will sometimes refuse patients that we refer for surgery...they don't want to have bad mortality statistics. Sometimes at that point, we'll go ahead and suck it up and have interventional cards stent the worst of their lesions.

I confess I didn't read the article yet, but those are some thoughts.

This is a very interesting debate that will go and on...
I think there is no question that surgery in general is more durable...but there is also no question that there are a significant number of patients who just don't want their chest to be cracked open, and for not always silly reasons. Also, sometimes after on pump CABG, people have neurologist damage that is hard to quantify...particularly in the case of elderly patients...sometimes patient or family will just relate that they "aren't the same" and stroke-like damage has been documented from this type of surgery. Complex PCI (such as left main stenting) has risks too, but the recovery time is almost always less and it doesn't require a sternotomy...

 

[dragonfly99]

And PCI techniques and the quality of stents HAS gotten better in the past few years. There have been several papers showing similar mortality for patients with left main coronary stenting versus CABG...while in the 70's and 80's that was definitely NOT true. If you have left main coronary stenting, then more risk of having to go back for repeat procedures later, but in the hands of the most skilled interventionalists and with the right stents and techniques, your mortality appears to be similar.