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Randomized Controlled Trial
. 2024 Aug 26;17(16):1861-1871.
doi: 10.1016/j.jcin.2024.06.003.

Outcomes According to Coronary Disease Complexity and Optimal Thresholds to Guide Revascularization Approach: FAME 3 Trial

Luke P Dawson  1 , Yuhei Kobayashi  2 , Frederik M Zimmermann  3 , Tatsunori Takahashi  4 , Christopher C Wong  5 , Pascal Theriault-Lauzier  5 , Nico H J Pijls  3 , Bernard De Bruyne  6 , Alan C Yeung  5 , Y Joseph Woo  5 , William F Fearon  7 ; FAME 3 Trial Investigators
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Free article
Randomized Controlled Trial

Outcomes According to Coronary Disease Complexity and Optimal Thresholds to Guide Revascularization Approach: FAME 3 Trial

Luke P Dawson et al. JACC Cardiovasc Interv. .
Free article

Abstract

Background: Coronary disease complexity is commonly used to guide revascularization strategy in patients with multivessel disease (MVD).

Objectives: The aim of this study was to assess the interactive effects of coronary complexity on percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) outcomes and identify the optimal threshold at which PCI can be considered a reasonable option.

Methods: A total of 1,444 of 1,500 patients with MVD from the FAME (Fractional Flow Reserve versus Angiography for Multi-vessel Evaluation) 3 randomized trial were included in the analysis (710 CABG vs 734 PCI). SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were transformed into restricted cubic splines, and logistic regression models were fitted, with multiplicative interaction terms for revascularization strategy. Optimal thresholds at which PCI is a reasonable alternative to CABG were determined on the basis of Cox regression model performance.

Results: The mean SYNTAX score (SS) was 25.9 ± 7.1. SS was associated with 1-year major adverse cardiac and cerebrovascular events among PCI patients and 3-year death, myocardial infarction, and stroke among CABG patients. Significant interactions were present between revascularization strategy and SS for 1- and 3-year composite endpoints (P for interaction <0.05 for all). In Cox regression models, outcomes were comparable between CABG and PCI for the 3-year primary endpoint for SS ≤24 (P = 0.332), with 44% of patients below this threshold and 32% below the conventional SS threshold of ≤22.

Conclusions: In patients with MVD without left main disease, PCI and CABG outcomes remain comparable up to SS values in the mid- rather than low 20s, which allows the identification of a greater proportion of patients in whom PCI may be a reasonable alternative to CABG.

Keywords: chronic coronary syndromes; coronary artery bypass graft surgery; coronary complexity; percutaneous coronary intervention.

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Conflict of interest statement

Funding Support and Author Disclosures This work was supported by grants from Medtronic and Abbott Vascular. Dr Dawson is supported by the Australian National Health and Medical Research Council and the Australian National Heart Foundation postgraduate scholarships. Dr Kobayashi serves as a consultant for Abbott Vascular. Dr Fearon has received institutional research support from Abbott Vascular, and Medtronic; and has stock options with HeartFlow. Dr De Bruyne has consulting relationships with Boston Scientific, Abbott Vascular, CathWorks, Siemens, and Coroventis Research; has received research grants from Abbott Vascular, Coroventis Research, CathWorks, and Boston Scientific; and holds minor equities in Philips-Volcano, Siemens, GE Healthcare, Edwards Lifesciences, HeartFlow, Sanofi, and Celyad. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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