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Observational Study
. 2023 Aug 7;44(30):2833-2842.
doi: 10.1093/eurheartj/ehad369.

PCI or CABG for left main coronary artery disease: the SWEDEHEART registry

Jonas Persson  1 , Jacinth Yan  2 , Oskar Angerås  3 , Dimitrios Venetsanos  4 , Anders Jeppsson  5   6 , Iwar Sjögren  7 , Rikard Linder  1 , David Erlinge  8 , Torbjörn Ivert  9 , Elmir Omerovic  3
Affiliations
Observational Study

PCI or CABG for left main coronary artery disease: the SWEDEHEART registry

Jonas Persson et al. Eur Heart J. .

Abstract

Aims: An observational nationwide all-comers prospective register study to analyse outcomes after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in unprotected left main coronary artery (LMCA) disease.

Methods and results: All patients undergoing coronary angiography in Sweden are registered in the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry. Between 01/01/2005 and 12/31/2015, 11 137 patients with LMCA disease underwent CABG (n = 9364) or PCI (n = 1773). Patients with previous CABG, ST-elevation myocardial infarction (MI) or cardiac shock were excluded. Death, MI, stroke, and new revascularization during follow-up until 12/31/2015 were identified using national registries. Cox regression with inverse probability weighting (IPW) and an instrumental variable (IV), administrative region, were used. Patients undergoing PCI were older, had higher prevalence of comorbidity but lower prevalence of three-vessel disease. PCI patients had higher mortality than CABG patients after adjustments for known cofounders with IPW analysis (hazard ratio [HR] 2.0 [95% confidence interval (CI) 1.5-2.7]) and known/unknown confounders with IV analysis (HR 1.5 [95% CI 1.1-2.0]). PCI was associated with higher incidence of major adverse cardiovascular and cerebrovascular events (MACCE; death, MI, stroke, or new revascularization) than CABG, with IV analysis (HR 2.8 [95% CI 1.8-4.5]). There was a quantitative interaction for diabetic status regarding mortality (P = 0.014) translating into 3.6 years (95% CI 3.3-4.0) longer median survival time favouring CABG in patients with diabetes.

Conclusion: In this non-randomized study, CABG in patients with LMCA disease was associated with lower mortality and fewer MACCE compared to PCI after multivariable adjustment for known and unknown confounders.

Keywords: Coronary artery bypass grafting; Cox regression; Instrumental variable analysis; Left main coronary artery disease; Mortality; Percutaneous coronary intervention.

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Conflict of interest statement

Conflict of interest J.P. has received unrestricted grants from Abbott Inc., unrelated to the present work. J.Y. has no conflicts of interest. O.A. has received research grant and lecture fees from Abbott Inc. D.V. has no conflicts of interest. A.J. has received fees for consultancy or lectures from AstraZeneca, Werfen, Portola, Baxter and LFB Biotechnologies, all unrelated to the present work. I.S. has no conflicts of interest. R.L. has no conflicts of interest. D.E. has no conflicts of interest. T.I. has no conflicts of interest. E.O. has no conflicts of interest.

Figures

Structured graphical abstract
Structured graphical abstract
CABG = coronary artery bypass grafting, CAD = coronary artery disease, CI = confidence interval, PCI = percutaneous coronary intervention, IPW adj. = inverse probability weighting adjustment, IV adj. = instrumental variable adjusted; MACCE = major adverse cardiovascular and cerebrovascular events.
Figure 1
Figure 1
Flowchart of patient selection. *Bare metal stent, bioresorbable vascular scaffold or self-expandable stent.
Figure 2
Figure 2
Outcome for PCI and CABG in left main coronary artery disease. The number of deaths, MI, stroke, revascularization, MACCE, and corresponding incidence rates for CABG and PCI, and crude and adjusted hazard ratios for PCI compared to CABG. IPW = inverse probability weighting, IV = instrumental variable.
Figure 3
Figure 3
Inverse probability weighting adjusted hazard ratios for mortality for PCI vs. CABG in subgroups.
Figure 4
Figure 4
Inverse probability weighting adjusted hazard ratios for MACCE for PCI vs. CABG in subgroups.
Figure 5
Figure 5
Inverse probability weighting adjusted median survival for mortality for PCI vs. CABG in the whole cohort and subgroups. Thin bar at point estimate = 95% confidence interval.
See this image and copyright information in PMC

Comment in

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