Week 19 – PCI vs CABG – the ASCERT study

A patient has triple vessel coronary artery disease and something must be done, they need revasularization. The end of their time with medical management only has been reached and now an intervention is needed. But what intervention should we be recommending? Should the patient be referred to the cardiothoracic surgeons for a coronary-artery bypass grafting (CABG) or to the intervention cardiologists for percutaneous coronary intervention (PCI)? Should we be recommending surgery or a minimally invasive procedure? What does the data tell us?

In the past 20 years there have been 12 randomised trials comparing these two interventions, over a time period in which there have been significant advances in both. Of course randomised control trials are one of the best forms of evidence based medicine but the results from trials may not be applicable to the patient sat in front of you, patient groups under study are selected and trials are carried out in selected centres. There is therefore a role for observational data which may reflect real life practice better. The ASCERT study set out to use such date from databases to compare the outcomes of PCI and CABG in two and three vessel disease.

Two different databases were used and over 180,000 patients were included in this study and only the first revascularization record was used for each patient. The primary end-point was all-cause mortality. It is of note that probably the biggest different between the two groups of patients were that patients in the PCI group were more likely to have had two-vessel disease whilst those in the CABG group more often had triple-vessel disease.

The results (patients aged over 65):

  • At 1 year, there was no significant difference in adjusted mortality between the groups (6.2% in the CABG group compared to 6.6% in the PCI group; risk ratio, 0.95; 95% confidence interval, 0.90 to 1.00).
  • However the ¬†adjusted 4-year mortality was 16.4% in the CABG group and 20.8% in the PCI group (risk ratio, 0.79; 95% CI, 0.76 to 0.82).

The 4-year risk ratios showed a benefit of CABG across subgroups studied and in both high and low risk groups (please see the paper for further details).

The author’s conclusion:

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.

We will be discussing the interesting paper on Sunday at 8pm

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2 Responses to Week 19 – PCI vs CABG – the ASCERT study

  1. David Lewis says:

    It is good to see this paper from NEJM being reviewed.

    Since I was given the choice of medical treatment versus surgical treatment for my own coronary artery disease after a NSTEMI it is satisfying to see the long term benefits of CABG.

    We forget that PCI does not prevent future MIs while quickly curing angina symptoms. On the other hand, CABG is a major operation and hurts like hell for several weeks after. Yet, CABG will prevent future MIs.

    It is a case of jam today vs jam tomorrow in the living stakes.

    I know what I would spend my money on and the ASCERT study is a wake up call to commissioners and health insurance companies: put more resources into training cardiac surgeons! Spend less on PCI, esp multivessel disease.

  2. Jack says:

    Intro: not sure suggestion that observational study is useful as it reflects real life, value is surely dramatic increase in numbers that can be studied. The price of this study design is the heterogeneity of the population shown in this study compounded by comparing treatment modalities in two different patient populations, 2 and three vessel disease.
    It would seem that the only conclusion would be that CABG of 3 vessel disease results in lower 4 year mortality than PCI in 2 vessel disease. It would be difficult to conclude that CABG of 2 vessel disease would have a lower mortality than PCI?
    #mytuppenceworth

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