A comparison of drug-eluting stent and coronary artery bypass grafting in mildly to moderately ischemic heart failure

Abstract

Aims: The best revascularization strategy for patients with ischaemic heart failure (IHF) remains unclear. Current evidence and guidelines mainly focus on patients with severe ischaemic heart failure (ejection fraction [EF] < 35%). There are limited data comparing clinical outcomes of coronary artery bypass grafting (CABG) with implantation of drug-eluting stents (DESs) in patients with mild to moderate ischaemic heart failure (EF 35-50%). It is therefore unknown whether percutaneous coronary intervention (PCI) with DES implantation can provide comparable outcomes to CABG in these patients.

Methods and results: From January 2016 to December 2017, we enrolled patients with mildly to moderately reduced EF (35-50%) who had undergone PCI with DESs or CABG. Patients with a history of CABG, presented with acute ST-elevation myocardial infarction (MI) or acute heart failure, and patients who had undergone CABG concomitant valvular or aortic surgery were excluded. Propensity score-matching analysis was performed between the two groups. Kaplan-Meier analysis and multivariate Cox proportional hazard regression were applied to assess all-cause mortality and individual end points. A total of 2050 patients (1330 PCIs and 720 CABGs) were included, and median follow-up was 45 months (interquartile range 40 to 54). There were significant differences in all-cause death between the two groups: 77 patients in the PCI group and 27 in the CABG group (DES vs. CABG: 5.8% vs. 3.8%, P = 0.045). After propensity score matching for the entire population, 601 matched pairs were obtained. The long-term cumulative rate of all-cause death was significantly different between the two groups (DES vs. CABG: 5.8% vs. 2.7%, P = 0.006). No differences were found in the rates of cardiac death (DES vs. CABG: 4.8% vs. 3.0%, P = 0.096), recurrent MI (DES vs. CABG: 4.0% vs. 2.8%, P = 0.234), and stroke (DES vs. CABG: 6.8% vs. 5.2%, P = 0.163). The rate of repeat coronary revascularization was significantly higher in the PCI group than in the CABG group (12.1% vs. 6.0%, P = 0.000).

Conclusions: Considering the higher long-term survival rate and lower repeat-revascularization rate, CABG may be superior to DES implantation in patients with mildly to moderately reduced EF (35-50%) and significant CAD.

Keywords: Coronary artery bypass grafting; Drug-eluting stent implantation; Ischaemic heart failure; Revascularization.