Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention for Stable Multivessel Coronary Disease in the Current Era.

Abstract

Recent changes to society-specific guidelines for the management of stable coronary artery disease (CAD) have challenged decades of data comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). We sought to compare index and longitudinal outcomes in these populations using a large contemporary real-world cohort. Using the United States Centers for Medicare and Medicaid Services database, we evaluated longitudinal outcomes of all beneficiaries aged ≥65 years undergoing multivessel CABG (n = 105,729) vs multivessel PCI (n = 13,192) for stable CAD (2018-2023). A predicted risk of index CABG mortality model, inclusive of frailty, was fit to simulate The Society of Thoracic Surgeons mortality model (area under the curve, 0.807). Doubly robust risk adjustment was performed with multivariable time-to-event analyses conducted in matched groups. Propensity score matching yielded well-balanced groups (n = 9206 per group) with a median age of 74 years, 71.2% men, and predicted mortality risk of 1.2%. Over the 6-year study period in this well-matched cohort, CABG was associated with superior longitudinal survival (hazard ratio [HR], 0.44; 95% CI, 0.40-0.49; P < .001) and freedom from myocardial infarction (HR, 0.40; 95% CI, 0.36-0.44; P < .001), coronary reintervention (HR, 0.10; 95% CI, 0.08-0.14; P < .001), and the composite outcome of myocardial infarction, coronary reintervention, or death (89.2% vs 71.1%; HR, 0.38; 95% CI, 0.35-0.41; P < .001). In Medicare beneficiaries with stable multivessel disease, CABG was associated with lower hospital mortality, superior longitudinal survival, and freedom from myocardial infarction and coronary reintervention. These contemporary real-world data support prior trials highlighting the benefits of CABG in stable multivessel CAD, urging a reevaluation of recent guidelines.