Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery

  1. Dena M. Bravata, MD, MS;
  2. Allison L. Gienger, BA;
  3. Kathryn M. McDonald, MM;
  4. Vandana Sundaram, MPH;
  5. Marco V. Perez, MD;
  6. Robin Varghese, MD, MS;
  7. John R. Kapoor, MD, PhD;
  8. Reza Ardehali, MD, PhD;
  9. Douglas K. Owens, MD, MS; and
  10. Mark A. Hlatky, MD
  1. From the Center for Primary Care and Outcomes Research and Stanford University School of Medicine, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California.

    Abstract

    Background: The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood.

    Purpose: To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated.

    Data Sources: MEDLINE, EMBASE, and Cochrane databases (1966–2006); conference proceedings; and bibliographies of retrieved articles.

    Study Selection: Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.

    Data Extraction: Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.

    Data Synthesis: The authors identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedure-related strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG–PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.

    Limitations: The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.

    Conclusion: Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures.

    Article and Author Information

    • Acknowledgment: The authors thank Ingram Olkin for guidance with statistical analyses, Artyom Sedrakyan for advice throughout the project, Olga Saynina for digitizing the survival curves, and Christopher D. Stave for assisting with the literature searches.

    • Grant Support: This report is based on research conducted by the Stanford-UCSF Evidence-based Practice Center under contract no. 290-02-0017 from the Agency for Healthcare Research and Quality.

    • Potential Financial Conflicts of Interest:Grants received: D.M. Bravata (Agency for Healthcare Research and Quality). Other: M.A. Hlatky (investigator for the BARI and AWESOME trials).

    • Requests for Single Reprints: Dena M. Bravata, MD, MS, Center for Primary Care and Outcomes Research, 117 Encina Commons, Stanford, CA 94305-6019; e-mail, dbravata{at}stanford.edu.

    • Current Author Addresses: Drs. Bravata and Owens, Ms. Gienger, Ms. McDonald, and Ms. Sundaram: Center for Primary Care and Outcomes Research, 117 Encina Commons, Stanford, CA 94305-6019.

    • Drs. Perez, Kapoor, and Ardehali: Department of Medicine, Stanford University School of Medicine, Falk Cardiovascular Research Center Building, 300 Pasteur Drive, Stanford, CA 94305.

    • Dr. Varghese: Division of Cardiac Surgery, Schulich School of Medicine, University of Western Ontario, Room B6-102, LHSC UH, 339 Windermere Road, London, Ontario N6A 5A5, Canada.

    • Dr. Hlatky: Department of Health Research and Policy, Stanford University School of Medicine, Redwood Building, T150A, Stanford, CA 94305-5405.

    • Author Contributions: Conception and design: D.M. Bravata, K.M. McDonald, V. Sundaram, M.V. Perez, R. Varghese, J.R. Kapoor, D.K. Owens, M.A. Hlatky.

    • Analysis and interpretation of the data: D.M. Bravata, M.V. Perez, J.R. Kapoor, R. Ardehali, D.K. Owens, M.A. Hlatky.

    • Drafting of the article: D.M. Bravata, J.R. Kapoor, D.K. Owens, M.A. Hlatky.

    • Critical revision of the article for important intellectual content: D.M. Bravata, A.L. Gienger, K.M. McDonald, V. Sundaram, M.V. Perez, R. Varghese, J.R. Kapoor, R. Ardehali, D.K. Owens, M.A. Hlatky.

    • Final approval of the article: D.M. Bravata, A.L. Gienger, K.M. McDonald, V. Sundaram, R. Varghese, D.K. Owens, M.A. Hlatky.

    • Provision of study materials or patients: D.M. Bravata, A.L. Gienger, M.A. Hlatky.

    • Statistical expertise: D.M. Bravata, D.K. Owens, M.A. Hlatky.

    • Obtaining of funding: D.M. Bravata, K.M. McDonald, D.K. Owens, M.A. Hlatky.

    • Administrative, technical, or logistic support: D.M. Bravata, A.L. Gienger, V. Sundaram, M.A. Hlatky.

    • Collection and assembly of data: D.M. Bravata, A.L. Gienger, V. Sundaram, M.V. Perez, R. Varghese, J.R. Kapoor, R. Ardehali, M.A. Hlatky.

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      Ann Intern Med published online October 26, 2009
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