Percutaneous vs. surgical revascularization of non-ST-segment elevation myocardial infarction with multivessel disease: the SWEDEHEART registry

Abstract

Background and aims: The long-term outcomes of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and multivessel disease remain debated.

Methods: The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry was used to analyse 57 097 revascularized patients with NSTEMI with multivessel disease in Sweden from January 2005 to June 2022. The primary endpoint was all-cause mortality, encompassing both in-hospital and long-term mortality; the secondary endpoints included myocardial infarction (MI), stroke, new revascularization, and heart failure. Multilevel logistic regression with follow-up time as a log-transformed offset variable and double-robust adjustment with the instrumental variable method were applied to control for known and unknown confounders.

Results: Percutaneous coronary intervention was the primary therapy in 42 190 (73.9%) patients, while 14 907 (26.1%) received CABG. Percutaneous coronary intervention patients were generally older with more prior cardiovascular events, whereas CABG patients had higher incidences of diabetes, hypertension, left main and three-vessel disease, and reduced ejection fraction. Over a median follow-up of 7.1 years, PCI was associated with higher risks of death [adjusted odds ratio (aOR) 1.67; 95% confidence interval (CI) 1.54-1.81] and MI (aOR 1.51; 95% CI 1.41-1.62) but there was no significant difference in stroke. Repeat revascularization was three times more likely to PCI (aOR 3.01; 95% CI 2.57-3.51), while heart failure risk was 15% higher (aOR 1.15; 95% CI 1.07-1.25). Coronary artery bypass grafting provided longer survival within 15 years, especially in patients under 70 years of age, with left main disease or left ventricular dysfunction, though this benefit diminished over shorter time horizons.

Conclusions: Coronary artery bypass grafting is associated with lower risks of mortality, MI, repeat revascularization, and heart failure in patients with NSTEMI, particularly in high-risk subgroups. However, its survival benefit lessens with shorter life expectancy.

Keywords: Coronary artery bypass grafting; Multivessel disease; Non-ST-segment elevation myocardial infarction; Percutaneous coronary intervention; Revascularization.

Graphical Abstract

This study, using data from the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry, compared the long-term outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention in patients with non-ST-elevation myocardial infarction (NSTEMI) and multivessel disease. Based on the causal inference methods with target trial emulation and instrumental variable analysis, CABG was found to be associated with lower risks of mortality, myocardial infarction, revascularization, and heart failure, particularly in high-risk patients, including those with left ventricular dysfunction, left main disease, and those under 70 years of age. These findings underscore the importance of CABG in managing high-risk patients with NSTEMI with multivessel disease and highlight the need for individualized treatment decisions based on patient-specific characteristics and expected outcomes. CABG, coronary artery bypass grafting; CI, confidence interval; OR, odds ratio; PCI, percutaneous coronary intervention.

Figure 1

Between 2005 and 2022, 533,957 unique patients were hospitalized and reported to the registry; 243 563 (45.6%) were diagnosed with myocardial infarction, and 290 394 (54.4%) had other diagnoses. Among the patients with non-ST-elevation myocardial infarction who fulfilled the inclusion criteria, 57 097 were identified. These were further categorized into 14 907 (26.1%) who underwent coronary artery bypass grafting and 42 190 (73.9%) who underwent percutaneous coronary intervention

Figure 2

Trends in the proportion of percutaneous coronary intervention as the method of choice for revascularization of patients with non-ST-elevation myocardial infarction in Sweden from 2005 to 22. The bar chart depicts the yearly percentage of patients undergoing percutaneous coronary intervention, illustrating a steady increase in its utilization since 2005

Figure 3

The considerable variation in the proportion of percutaneous coronary intervention utilization across different hospitals in Sweden. The use of percutaneous coronary intervention varied significantly, ranging from 55% in some hospitals to nearly 92% in others. This considerable variation indicates differences in the preference and possibly the availability of percutaneous coronary intervention to revascularize patients with non-ST-elevation myocardial infarction among hospitals. This substantial variation indicates a lack of standardization in using coronary artery bypass grafting and percutaneous coronary intervention for managing patients with non-ST-elevation myocardial infarction in Swedish hospitals

Figure 4

Kaplan–Meier curves for all-cause mortality in patients with CS. (A) All-cause mortality in patients revascularized with coronary artery bypass grafting and percutaneous coronary intervention. (B) Risk of myocardial infarction. (C) Risk of stroke. (D) Risk of heart failure

Figure 4

Kaplan–Meier curves for all-cause mortality in patients with CS. (A) All-cause mortality in patients revascularized with coronary artery bypass grafting and percutaneous coronary intervention. (B) Risk of myocardial infarction. (C) Risk of stroke. (D) Risk of heart failure

Figure 5

A subgroup analysis for age, sex, diabetes, presence of left main disease, and ejection fraction. The data are presented as a forest plot, which summarizes the odds ratios and 95% confidence intervals of the different subgroups on mortality. The results of the subgroup analysis indicated that the effect of revascularization with coronary artery bypass grafting varied across some subgroups. There was evidence for quantitative interaction with a higher risk with percutaneous coronary intervention adults < 70 years, patients with left main disease, and patients with lower ejection fraction. There was no interaction between the revascularization methods and sex and diabetes