Mortality advantage with CABG over PCI in Medicare patients

April 22, 2013

San Francisco, CA - A comparative-effectiveness study of CABG surgery in a population of real-world patients and providers has shown that CABG surgery is associated with an 8% lower risk of death compared with PCI.

These results, according to the researchers, are in line with a previous analysis of 10 randomized trials and other trials. "This body of evidence suggests that the use of CABG rather than PCI is likely to reduce mortality for the average patient with multivessel coronary disease," write Dr Mark Hlatky (Stanford University School of Medicine, CA) and colleagues.

This reduction in mortality with CABG was significantly lower among patients with diabetes, a history of tobacco use, heart failure, and peripheral artery disease, providing strong evidence that clinical characteristics modify the CABG-PCI treatment effect, add the researchers.

More than
100
  000 matched patients

The results, from an observational comparison of 105 156 propensity score-matched Medicare patients, are published April 22, 2013 in the Annals of Internal Medicine. The baseline clinical characteristics of the matched patients were similar between patients who received CABG and those who received PCI. The average patient, according to the researchers, was 75 years old, white, had hypertension, and was followed for a median of 4.3 years.

The survival rate after five years was 74.1% for CABG and 71.9% for PCI, a difference that translated into a statistically significant all-cause mortality hazard ratio [HR] of 0.92 (95% CI 0.90-0.95). The interaction with race and treatment was due to the inclusion of "other races," report the researchers, as there was no interaction between mortality and treatment among white and black patients.

Kaplan-Meier survival estimates and CABG-PCI hazard ratios

Characteristic
CABG, 5-y survival (%)
PCI, 5-y survival (%)
Hazard ratio (95% CI)
All patients
74.1
71.9
0.92 (0.90-0.95)
Diabetics
69.6
66.1
0.88 (0.84-0.91)
Nondiabetics
76.2
74.7
0.95 (0.92-0.98)
Tobacco use
76.0
71.0
0.82 (0.77-0.88)
No tobacco use
73.7
72.1
0.94 (0.92-0.97)
Peripheral artery disease
65.7
59.8
0.85 (0.80-0.89)
No peripheral artery disease
75.8
74.5
0.95 (0.92-0.98)
Heart failure
51.7
44.6
0.84 (0.79-0.88)
No heart failure
77.5
76.2
0.96 (0.93-0.98)
White
74.5
72.2
0.91 (0.89-0.94)
Black
67.1
65.9
0.98 (0.88-1.10)
Other race
71.3
73.5
1.14 (0.98-1.31)

Based on individualized predictions of survival in the five-year period postrevascularization, the researchers say that approximately 0.053 life-years would be gained if patients were treated with surgery rather than PCI. "The number of life-years added by CABG over five years is an underestimate of the lifetime effect of treatment, because the CABG and PCI survival curves are separated for up to 10 years and subsequent follow-up is limited," write Hlatky and colleagues.

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