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Comparative Study
. 2012 Apr 19;366(16):1467-76.
doi: 10.1056/NEJMoa1110717. Epub 2012 Mar 27.

Comparative effectiveness of revascularization strategies

William S Weintraub  1 , Maria V Grau-Sepulveda, Jocelyn M Weiss, Sean M O'Brien, Eric D Peterson, Paul Kolm, Zugui Zhang, Lloyd W Klein, Richard E Shaw, Charles McKay, Laura L Ritzenthaler, Jeffrey J Popma, John C Messenger, David M Shahian, Frederick L Grover, John E Mayer, Cynthia M Shewan, Kirk N Garratt, Issam D Moussa, George D Dangas, Fred H Edwards
Affiliations
Comparative Study

Comparative effectiveness of revascularization strategies

William S Weintraub et al. N Engl J Med. .

Abstract

Background: Questions persist concerning the comparative effectiveness of percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG). The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) collaborated to compare the rates of long-term survival after PCI and CABG.

Methods: We linked the ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008. Outcomes were compared with the use of propensity scores and inverse-probability-weighting adjustment to reduce treatment-selection bias.

Results: Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00). 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). Similar results were noted in multiple subgroups and with the use of several different analytic methods. Residual confounding was assessed by means of a sensitivity analysis.

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. (Funded by the National Heart, Lung, and Blood Institute.).

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Conflict of interest statement

No other potential conflict of interest relevant to this article was reported.

Figures

Figure 1
Figure 1. Propensity Scores for Coronary Artery Bypass Grafting (CABG) in the Percutaneous Coronary Intervention (PCI) and CABG Populations
The propensity score for CABG is the probability given baseline variables that any patient in either group would be selected for CABG.
Figure 2
Figure 2. Rates of Survival in the CABG and PCI Populations, from an Unadjusted Analysis
Cumulative mortality with CABG and with PCI and the relative risk of CABG as compared with PCI are shown.
Figure 3
Figure 3. Rates of Survival in the CABG and PCI Populations, from an Analysis Adjusted with the Use of Inverse Probability Weighting
Cumulative mortality with CABG and with PCI and the relative risk of CABG as compared with PCI are shown. The inset shows the same data on an enlarged y axis.
Figure 4
Figure 4. Effect of Unmeasured Confounding Factors
Shown is a sensitivity analysis that illustrates how powerful a single confounder would have to be to account for the advantage of CABG over PCI that was detected in the adjusted analysis. A single unmeasured confounder could produce the observed survival differences only if it increased the long-term risk of death by a factor of approximately two or if the long-term risk of death was three to five times as high in the PCI group as in the CABG group. For example, if a confounder was present in 10% of the patients in the CABG group (green curved line) but in 35% of patients in the PCI group (x axis), and if it increased the risk of death by a factor of slightly more than two (hazard ratio, 2.09), then that confounder alone could itself account for the observed difference in mortality between the study groups.
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References

    1. Hlatky MA, Boothroyd DB, Bravata DM, et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet. 2009;373:1190–7. - PubMed
    1. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360:961–72. - PubMed
    1. Douglas PS, Brennan JM, Anstrom KJ, et al. Clinical effectiveness of coronary stents in elderly persons: results from 262,700 Medicare patients in the American College of Cardiology-National Cardiovascular Data Registry. J Am Coll Cardiol. 2009;53:1629–41. - PMC - PubMed
    1. Rosenbaum PR, Rubin D. The central role of propensity score in observation studies for causal effects. Biometrika. 1983;70:41–55.
    1. Curtis LH, Hammill BG, Eisenstein EL, Kramer JM, Anstrom KJ. Using inverse probability-weighted estimators in comparative effectiveness analyses with observational databases. Med Care. 2007;45(Suppl 2):S103–S107. - PubMed

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