JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER INC.

VOL. 64, NO. 25, 2014

ISSN 0735-1097/$36.00
http://dx.doi.org/10.1016/j.jacc.2014.09.074

ORIGINAL INVESTIGATIONS

Coronary Artery Bypass Graft Surgery

Versus Drug-Eluting Stents for Patients
With Isolated Proximal Left Anterior
Descending Disease
Edward L. Hannan, PHD,* Ye Zhong, MD,* Gary Walford, MD,y David R. Holmes, JR, MD,z Ferdinand J. Venditti, MD,x
Peter B. Berger, MD,k Alice K. Jacobs, MD,{ Nicholas J. Stamato, MD,# Jeptha P. Curtis, MD,** Samin Sharma, MD,yy
Spencer B. King III, MDzz

ABSTRACT
BACKGROUND Few recent studies have compared the outcomes of coronary artery bypass graft (CABG) surgery with
percutaneous coronary interventions (PCIs) in patients with isolated (single vessel) proximal left anterior descending
(PLAD) coronary artery disease in the era of drug-eluting stents (DES).
OBJECTIVES The goal of this study was to compare outcomes in patients with PLAD who underwent CABG and PCI
with DES.
METHODS New Yorks Percutaneous Coronary Interventions Reporting System was used to identify and track all
patients who underwent CABG surgery and received DES for isolated PLAD disease between January 1, 2008 and
December 31, 2010, and who were followed-up through December 31, 2011. A total of 5,340 of 6,064 (88%) patients
received DES. Patients were matched to vital statistics data to obtain mortality after discharge and matched to New
Yorks administrative data to obtain readmissions for myocardial infarction (MI) and stroke. To minimize selection
bias, patients were propensity matched into 715 CABG and/or DES pairs, and 3 outcome measures were compared
across the pairs.
RESULTS Kaplan-Meier estimates for CABG and DES did not signicantly differ for mortality or mortality, MI, and/or
stroke, but repeat revascularization rates were lower for CABG (7.09% vs. 12.98%; p 0.0007). After further adjustment with Cox proportional hazards models, there were still no signicant differences in 3-year mortality rates (CABG
and/or DES adjusted hazard ratio (AHR): 1.14; 95% condence interval [CI]: 0.70 to 1.85) or mortality, MI, and/or stroke
rates (AHR: 1.15; 95% CI: 0.76 to 1.73), and the repeat revascularization rate remained signicantly lower for CABG
patients (AHR: 0.54; 95% CI: 0.36 to 0.81).
CONCLUSIONS Despite the higher rating in current guidelines of CABG (Class IIa vs. Class IIb) for patients with isolated
PLAD disease, there were no differences in mortality or mortality, MI, and/or stroke, although CABG patients had
signicantly lower repeat revascularization rates. (J Am Coll Cardiol 2014;64:271726) 2014 by the American College
of Cardiology Foundation.

From the *University at Albany, State University of New York, Albany, New York; yJohns Hopkins University, Baltimore,
Maryland; zMayo Clinic, Rochester, Minnesota; xAlbany Medical Center, Albany, New York; kGeisinger Medical Center, Danville,
Pennsylvania; {Boston Medical Center, Boston, Massachusetts; #United Health Services, Binghamton, New York; **Yale School of
Medicine, New Haven, Connecticut; yyMount Sinai Medical Center, New York, New York; and the zzSt. Josephs Health System,
Atlanta, Georgia. Dr. Curtis has equity interest in Medtronic. Dr. Sharma has received research grant support from Boston Scientic Inc.; and serves on the speakers bureau of Boston Scientic Inc., Abbott Vascular, Eli Lilly, The Medicine Co., Angioscore,

2718

Hannan et al.

JACC VOL. 64, NO. 25, 2014

CABG and PCI Outcomes for Proximal LAD

DECEMBER 30, 2014:271726

ABBREVIATIONS
AND ACRONYMS
ACCF = American College of

ndings

atients with severe coronary artery

result

disease (CAD) are generally recom-

risk), medical therapy use (none and/or minimal,

mended for either coronary artery

maximal), and Canadian Cardiovascular Class angina

(low,

intermediate,

and

high

bypass graft (CABG) surgery or percutaneous

(none, class I or II, class III or IV) (33,35,3840). How-

coronary intervention (PCI). Most patients

ever, the AUC do not rate CABG surgery versus PCI in

Heart Association

with severe CAD have multivessel disease

patients with single-vessel PLAD disease, although

AHR = adjusted hazard ratio

(at least 2 major coronary arteries with

these criteria do compare the 2 procedures for many

AUC = appropriate use criteria

stenosis $70%). Many randomized controlled

combinations of patients with multivessel CAD (41).

Cardiology Foundation

AHA = American

trials (RCTs) and observational studies have

CABG = coronary artery

examined

these

3-year outcomes for CABG surgery and DES in

CAD = coronary artery disease

procedures in an effort to determine which

patients with isolated single-vessel PLAD disease.

procedure is preferable for specic patients

Outcomes included all-cause mortality, the combined

(115).

outcome of mortality, myocardial infarction (MI),

CI = condence interval
CSRS = Cardiac Surgery

relative

Reporting System

outcomes

for

The main purpose of this study was to compare

bypass graft

and/or stroke, and repeat revascularization.

SEE PAGE 2727

DES = drug-eluting stent(s)

However,

MI = myocardial infarction

patients

with

single-vessel

METHODS

proximal left anterior descending (PLAD)

PCI = percutaneous
coronary intervention

artery disease are regarded as high risk

ENDPOINTS. Endpoints in the study included 3-year

PCIRS = Percutaneous

compared to other patients with single-

mortality, mortality, MI, and/or stroke, and repeat

Coronary Interventions

vessel

is

revascularization. The mean follow-up was 2.5 years

Reporting System

frequently considered for these patients as

because all procedures between January 1, 2008 and

PLAD = proximal left

well. There were at least 9 RCTs (forming the

December 31, 2010 were followed for 3 years or until

basis for 17 studies) that compared CABG

December 31, 2011.

anterior descending

RCT = randomized

disease,

and

revascularization

surgery and PCIs in these patients (1632).

DATABASES. The primary databases used for the

However, the total number of patients

study were New York States clinical registries

Cardiovascular Angiography

enrolled in these trials was quite modest

for PCI and for CABG surgery, the Percutaneous

and Interventions

(n 1,210); 7 of the 9 trials were single-center

Coronary Interventions Reporting System (PCIRS)

SPARCS = Statewide

studies, and most were conducted in Europe.

and the Cardiac Surgery Reporting System (CSRS),

Planning and Research

Furthermore, only 1 trial was conducted in

respectively. These registries contain detailed infor-

the era of drug-eluting stents (DES). A single

mation on patient demographic characteristics, risk

study enrolled patients as late as 2003, and all of the

factors, hemodynamic state, left ventricular func-

other studies enrolled patients in 2001 or earlier, with

tion, the number of diseased coronary vessels and

8 studies of patients enrolled before 2000. Thus,

the number of vessels treated, complications, pro-

controlled trial

SCAI = Society for

Cooperative System

there is good reason to learn more about the

cedure choices, provider identiers, discharge sta-

comparative outcomes for CABG surgery and PCIs in

tus, and in-hospital adverse outcomes. PCIRS also

these patients in the era of DES.

contains information on the type(s) of device(s) used

The latest guidelines (2011) issued by the American

College of Cardiology Foundation (ACCF)/American

for each attempted lesion, including the type and

brand of stent used.

Heart Association (AHA)/Society for Cardiovascular

Completeness of data reporting is monitored by

Angiography and Interventions (SCAI) rates CABG

matching PCIRS to New Yorks acute care hospital

surgery as class IIa (benet exceeds risk) when done

discharge database, the Statewide Planning and

with a left internal mammary artery graft (3337). The

Research Cooperative System (SPARCS), and to the

latest (2012) Appropriate Use Criteria (AUC) published

Department of Healths Ambulatory Surgery Data-

by the ACCF and a few other professional societies

base, and identifying any cases reported in those

consider revascularization (PCI or CABG surgery) to be

databases that were not reported in the cardiac

appropriate for patients with single-vessel PLAD dis-

registries. SPARCS contains patient demographic

ease for 12 of the 18 combinations of noninvasive test

characteristics (age, sex, and race), diagnoses and

Boston Scientic Corporation, Cardiovascular Systems Inc., and DSI/Lilly. Dr. King has received payment for serving on the
advisory boards of Medtronic, Merck & Co., Inc., Wyeth, Capricor, Harvard Clinical Research Institute, and Duke University; and
receives minimal consulting fees as a scientic advisor for Celanova. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.James Forrester, MD, served as Guest Editor for this paper.
Manuscript received May 17, 2014; revised manuscript received September 8, 2014, accepted September 14, 2014.

JACC VOL. 64, NO. 25, 2014

Hannan et al.

DECEMBER 30, 2014:271726

CABG and PCI Outcomes for Proximal LAD

T A B L E 1 Patient Characteristics Before Propensity Matching

T A B L E 1 Continued

2008 to 2010 New York State Patients With Single-Vessel

Proximal Left Anterior Descending Disease Undergoing CABG

Risk Factor

Surgery and Stenting With DES

All Patients
CABG
DES
(n 6,064) (n 724) (n 5,340) p Value

Peripheral vascular disease

Risk Factor

All Patients
CABG
DES
(n 6,064) (n 724) (n 5,340) p Value

Age, yrs
11.4

11.3

11.4

5054

10.6

10.1

10.7

5559

14.5

13.7

14.6

6064

16.5

18.2

16.3

6569

15.4

17.3

15.2

7074

12.1

11.7

12.1

7579

10.0

9.9

10.0

8084

6.6

5.7

6.7

$85

2.9

2.1

3.0

0.54

Male

63.3

67.0

62.8

Female

36.7

33.0

37.2

96.4

99.9

99.9

99.9

0.1

0.1

0.1

8.4

6.8

8.6

91.6

93.2

91.4

White

83.3

86.7

82.8

Black

7.6

7.6

7.6

Other

9.1

5.7

9.6

<16.5

0.2

0.7

0.2

16.518.4

0.6

1.0

0.5

18.524.9

20.8

23.9

20.3

25.030.0

38.8

37.7

39.0

30.134.9

23.7

22.5

23.8

35.040.0

10.0

9.5

10.1

6.0

4.7

6.2

0.4

1.0

0.3

<0.0001

0.03

0.09

0.003

0.006

Ejection fraction, %
1.9

1.5

1.9

3039

4.5

6.9

4.1

4049

10.1

15.6

9.4

$50

83.1

75.0

84.2

0.47

95.5

93.7

95.8

At current admission

3.2

4.4

3.0

Before current
admission

1.3

1.9

1.2

0.03

Malignant ventricular arrhythmia

Body mass index, kg/m2

2029

Stable

None

Race

119

3.7

92.8

Congestive heart failure

Ethnicity

>40.0

7.2

95.9

Unstable

Sex

Non-Hispanic

4.1

No
Hemodynamic state

<50

Hispanic

Yes

<0.0001

Yes

0.4

1.0

0.3

No

99.6

99.0

99.7

0.01

Chronic obstructive pulmonary disease

Yes

7.5

19.6

5.9

No

92.5

80.4

94.1

Yes

25.8

26.0

25.7

No

74.2

74.0

74.3

Creatinine:
<1.2 mg/dl,
no dialysis

76.4

73.2

76.8

Creatinine:
1.21.5 mg/dl,
no dialysis

18.4

20.6

18.1

Creatinine:
1.62.0 mg/dl,
no dialysis

2.9

3.2

2.9

Creatinine:
2.12.5 mg/dl,
no dialysis

0.6

0.3

0.6

Creatinine:
2.63.0 mg/dl,
no dialysis

0.2

0.1

0.2

Creatinine:
>3.0 mg/dl,
no dialysis

0.3

0.6

0.3

Dialysis

1.3

2.1

1.1

<0.0001

Diabetes
0.89

Renal failure
0.09

Previous myocardial infarction

13.3

14.6

13.1

814 days

17 days

1.0

3.5

0.7

1520 days

0.2

0.6

0.2

$21 days
No myocardial
infarction in
past 1 days

5.8

11.5

5.0

79.7

69.9

81.1

<0.0001

Values are %.
CABG coronary artery bypass graft; DES drug-eluting stent(s).

with patient identiers and admission, surgery, and

discharge dates. In-hospital outcomes were also

Cerebrovascular disease
Yes

5.5

11.2

4.7

No

94.5

88.8

95.3

<0.0001

Continued in the next column

matched to SPARCS to ensure accuracy. The Department of Healths utilization review agent audits
samples of records from hospitals to ensure the
accuracy of risk factor reporting. SPARCS data were
also used to identify subsequent emergency admissions with MI and stroke as the principal diagnoses

procedures, admission and discharge dates, and

because the combined endpoint of mortality, MI,

discharge disposition for all patients discharged from

and/or stroke was one of the outcomes evaluated in

nonfederal acute care hospitals in New York. PCIRS

this study.

and CSRS records were matched with SPARCS

Patient identiers in the PCIRS and CSRS were

records using unique hospital identiers together

used to link patients who underwent the index

2719

2720

Hannan et al.

JACC VOL. 64, NO. 25, 2014

CABG and PCI Outcomes for Proximal LAD

DECEMBER 30, 2014:271726

revascularization procedure to future admissions in

model were more than 2 SDs apart. Differences be-

PCIRS and CSRS to identify repeat revascularization,

tween the 2 matched samples in the prevalence of

and to link the index procedure to New York States

propensity model variables were tested using stan-

vital statistics data to identify deaths that occurred

dardized differences in the observed prevalence of the

after discharge.

variables in the matched groups (46). The propensity-

PATIENTS AND HOSPITALS. A total of 90,686 pa-

tients underwent PCIs with DES, and a total of 26,323

patients underwent isolated CABG surgery between
January 1, 2008 and December 31, 2010. We excluded
those patients who had previous revascularization
(n 40,457), had pre-procedural cardiogenic shock
(n 101), had left main disease (n 8,170), had a MI
within 24 h before the index procedure (n 8,851),
were from out of state (n 1,966), had multivessel
disease (n 51,141), had multiple revascularizations
in the same admission (n 7), or who had missing
ejection fraction values (n 252). All other patients
who underwent revascularization for isolated PLAD
disease (dened as the region before the origin of the
major septal artery) between January 1, 2008 and
December 31, 2010 in New York state (6,064 patients,
of whom 5,340 received DES and 724 of whom
underwent CABG surgery) were followed through the
end of 2011 to compare mortality, mortality, MI,
and/or stroke, and subsequent revascularization for
DES and CABG surgery patients. There were 57 hospitals where these patients underwent revascularization during this period.

matched pairs were then used to analyze differences

in outcomes between DES and CABG surgery without
using any of the data for unmatched patients in subsequent analyses. Remaining differences were further
reduced by using Cox proportional hazards models for
adjustment, along with robust SEs to control for
clustering of patients in matched pairs, and taking
into account that the samples were matched (47). All
variables used in the propensity score were used in
the Cox model adjustment.
Propensity-matched pairs with Cox proportional
hazards adjustment were also obtained and analyzed
for the subset of revascularized patients who did not
experience an acute MI any time before undergoing
revascularization. CABG and DES outcomes were also
compared in patients with diabetes.
All tests were 2-sided and conducted at the
0.05 level, and all analyses were conducted in SAS
9.2 (SAS Institute, Cary, North Carolina).

RESULTS
Table 1 presents differences in patient characteristics
for patients with single-vessel PLAD disease who

STATISTICAL ANALYSIS. The use of DES and CABG

received DES and underwent CABG surgery in New

surgery for single-vessel LAD disease was com-

York between 2008 and 2010. As indicated, in com-

pared for numerous patient characteristics, including

parison to CABG surgery patients, DES patients were

demographics, comorbidities, ventricular function,

more likely to be women, of a race other than white or

pre-procedural MI, and hemodynamic state. Chi-

black, had higher body mass indexes and higher

square tests were used to determine signicant

ejection fractions, and were less likely to have had a

differences in the use of the 2 types of revasculari-

previous MI, cerebrovascular disease, peripheral

zation for each patient characteristic.

vascular disease, congestive heart failure, malignant

Because patients were not randomized to DES and

CABG surgery, and because the prevalence of many of

ventricular arrhythmia, or chronic obstructive pulmonary disease (Central Illustration).

sig-

Unadjusted mortality and mortality, MI, and/or

nicantly different, propensity score matching was

stroke outcomes for all patients before propensity

used to identify sets of DES and/or CABG surgery pairs

matching were signicantly lower for DES patients

matched to those characteristics so that the selection

(4.3% vs. 5.9%, p 0.04 and 6.1% vs. 8.3%, p 0.03,

bias associated with our observational study could be

respectively), but repeat revascularization rates were

minimized. To derive the propensity score, a logistic

signicantly higher for DES patients (12.2% vs. 6.5%,

regression model was developed that predicted the

p < 0.0001). The 12.2% consisted of 11.2% PCIs and

probability that a given patient would receive CABG

1.0% CABG surgery, and the 6.5% consisted of 6.2%

surgery on the basis of the patient characteristics

PCIs and 0.3% CABG surgery.

the

characteristics

mentioned

earlier

were

described earlier. This value, the propensity score,

The propensity match yielded a set of 1,430

was used to match patients without replacement on

propensity-matched

a 1-to-1 basis to minimize the overall distance in pro-

and/or DES pairs). After propensity matching, the

patients

(715

CABG

surgery

pensity scores between the groups (4245). Patients

characteristics of CABG surgery and DES patients

from the DES and CABG groups were matched unless

were very similar, as evidenced by none of the stan-

their estimated log-odds from the logistic regression

dardized differences exceeding 10.0 (Table 2).

JACC VOL. 64, NO. 25, 2014

Hannan et al.

DECEMBER 30, 2014:271726

CABG and PCI Outcomes for Proximal LAD

T A B L E 2 Patient Characteristics After Propensity Matching

2721

T A B L E 2 Continued

2008 to 2010 New York State Patients with Single-Vessel

Proximal Left Anterior Descending Disease Undergoing CABG
Surgery and Stenting with DES

Risk Factor

All Patients CABG

DES
Standardized
(n 1,430) (n 715) (n 715) Difference

Age, yrs
<50

11.3

11.1

11.6

1.76

5054

9.3

5559

13.4

10.1

8.5

5.30

13.9

13.0

2.46

6064
6569

18.7

18.5

19.0

1.43

16.4

17.1

15.8

3.39

7074

13.3

11.8

14.8

9.07

7579

10.0

10.1

9.9

0.47

8084

5.5

5.6

5.3

1.23

$85

2.0

2.1

2.0

0.99

Female

34.4

33.2

35.7

5.30

6.4

6.9

5.9

4.01

86.8

86.6

87.0

1.24

Hispanic ethnicity
Race
White
Black

7.8

7.7

8.0

1.04

Other

5.4

5.7

5.0

3.10

0.6

0.7

0.6

1.77

Body mass index,

kg/m2
<16.5
16.518.4

1.0

1.0

1.0

0.00

18.524.9

24.8

24.2

25.3

2.59

25.030.0

36.9

37.2

36.5

1.45
0.00

Risk Factor

All Patients CABG

DES
Standardized
(n 1,430) (n 715) (n 715) Difference

Chronic obstructive
pulmonary
disease

18.6

18.7

18.5

0.72

Diabetes

26.0

25.9

26.2

0.64

Creatinine:
<1.2 mg/dl,
no dialysis

73.8

73.4

74.1

1.59

Creatinine:
1.21.5 mg/dl,
no dialysis

20.4

20.3

20.4

0.35

Creatinine:
1.62.0 mg/dl,
no dialysis

2.9

3.2

2.5

4.19

Creatinine:
2.12.5 mg/dl,
no dialysis

0.3

0.3

0.3

0.00

Creatinine:
2.63.0 mg/dl,
no dialysis

0.1

0.1

0.1

0.00

Creatinine:
>3.0 mg/dl,
no dialysis

0.6

0.6

0.7

1.77

Dialysis

2.0

2.1

1.8

2.02

Renal failure

Values are %.
Abbreviations as in Table 1.

30.134.9

22.7

22.7

22.7

35.040.0

9.2

9.7

8.8

2.90

Table 3 presents 3-year outcomes for propensity-

>40.0

4.9

4.6

5.2

2.59

matched CABG surgery and DES patients. As indi-

0.6

0.7

0.6

1.77

mortality rates (CABG and/or DES adjusted hazard

ratio [AHR]:1.14; 95% condence interval [CI]: 0.70 to

cated, there were no signicant differences in 3-year

Ejection fraction, %
119
2029

1.3

1.5

1.1

3.66

3039

7.1

6.9

7.4

2.17

4049

17.1

15.5

18.6

8.18

$50

73.9

75.4

72.3

7.00

95% CI: 0.76 to 1.73). However, the rates for repeat

revascularization were signicantly lower for CABG

Previous myocardial
infarction
17 days

1.85) or mortality, MI, and/or stroke rates (AHR: 1.15;

patients (AHR: 0.54; 95% CI: 0.36 to 0.81) (Central

14.8

14.6

15.1

1.57

Illustration). Kaplan-Meier curves for each of the

814 days

2.9

2.9

2.8

0.84

3-year outcomes are presented in Figure 1.

1520 days

0.6

0.6

0.6

0.00

$21 days

10.8

11.2

10.4

2.71

No myocardial
infarction in
past 1 days

71.0

70.8

71.2

0.92

Cerebrovascular
disease

before the procedure, there were still no differences

10.0

10.5

9.5

3.26

Peripheral vascular
disease

6.7

6.7

6.7

0.00

Unstable
hemodynamic
state

0.2

0.1

0.3

3.05

T A B L E 3 3-Year Outcomes for Propensity-Matched Patients With Single-Vessel Proximal

December 31, 2011

Observed Rate
Longer-Term Outcomes

94.3

94.1

94.6

1.81

At current
admission

3.9

3.9

3.8

0.73

Before current
admission

1.8

2.0

1.7

2.09

0.8

1.0

0.7

3.06

Malignant ventricular
arrhythmia

Left Anterior Descending Disease Receiving CABG Surgery and Stenting With DES in
New York State: January 1, 2008 to December 31, 2010 and Followed Through to

Congestive heart
failure
None

When the analyses were restricted to pairs of

patients who did not experience an MI at any time

Continued in the next column

Kaplan-Meier
Estimates

CABG

DES

CABG

DES

CABG/DES

Mortality

5.45

4.76

6.59

6.24

1.14 (0.701.85)

p Value

0.61

Mortality/MI/stroke

7.83

6.43

10.47

8.83

1.15 (0.761.73)

0.52

Repeat revascularization

5.87

10.77

7.09

12.98

0.54 (0.360.81)

0.003

Values are % or AHR (95% CI).

AHR adjusted hazard ratio; CI condence interval; MI myocardial infarction; other abbreviations
as in Table 1.

2722

Hannan et al.

JACC VOL. 64, NO. 25, 2014

CABG and PCI Outcomes for Proximal LAD

DECEMBER 30, 2014:271726

CENT RAL I LLU ST RATI ON

DES Versus CABG for Isolated PLAD: Differences in Patient Characteristics and Outcomes

RECOMMENDED TREATMENT TREND* FOR PATIENTS WITH ISOLATED PLAD

Coronary Artery Bypass Graft (CABG) Surgery
Drug-Eluting Stents (DES)
DES patients more likely to:
be women
be a race other than white or black
have higher body mass indices
have higher ejection fractions
not have had a previous myocardial infarction, cerebrovascular disease,
peripheral vascular disease, congestive heart failure, malignant ventricular
arrhythmia, or chronic obstructive pulmonary disease

88% DES

* In a population of 6,064 patients undergoing treatment for isolated

PLAD, New York, 1/01/0812/31/11

COMPARATIVE MATCHED PATIENT OUTCOME AT 3-YEAR FOLLOW-UP

12%

6%

5.45%

4.76%

7.83%

6.43%

5.87%

10.77%

0
Mortality

Mortality, stroke,
or myocardial infarction

Repeat
revascularization

Hannan, E.L. et al. J Am Coll Cardiol. 2014; 64(25):271726.

CABG coronary artery bypass graft; DES drug-eluting stent(s); PLAD proximal left anterior descending.

in 3-year mortality (AHR: 1.31; 95% CI: 0.67 to 2.55)

ratings for patients with single-vessel PLAD disease.

or mortality, MI, and/or stroke (AHR: 0.96; 95% CI:

For example, the latest (2011) guidelines for PCIs

0.86 to 1.06), but repeat revascularization rates were

issued by ACCF/AHA/SCAI rates CABG surgery with a

again lower for CABG surgery patients (AHR: 0.53;

left internal mammary artery graft for long-term

95% CI: 0.35 to 0.80). There were also no signicant

benet as Class IIa (benet exceeds risk; additional

differences in mortality or mortality, MI, and/or

studies with focused objectives are needed, and it is

stroke for the 182 pairs of patients with diabetes

reasonable to perform the procedure) (3337). These

(AHR: 1.00; 95% CI: 0.41 to 2.43 and AHR: 0.95; 95%

guidelines also rate PCIs as Class IIb (additional

CI: 0.44 to 2.06, respectively), although repeat

studies with broad objectives are needed; additional

revascularization rates favored CABG (AHR: 0.33;

registry data would be helpful; and the procedure

95%: 0.15 to 0.72).

may be considered) (33,35,3840). These ratings are

each relative to a strategy of medical therapy only.

DISCUSSION

The latest AUC, the ACCF/SCAI/STS/AATS/AHA/

ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for

Recent guidelines and AUC published jointly by the

Coronary Revascularization Focused Update, state

ACCF, the AHA, and other professional societies have

that revascularization is appropriate for many subsets

supplied guidance related to the treatment of pa-

of patients with single-vessel PLAD disease on the

tients with severe CAD who are candidates for 1 of the

basis of information about their use of medical ther-

3 common treatment methods: medical therapy, PCI,

apy, their stress test ndings, and the severity of their

and CABG surgery. Included in these documents are

anginal symptoms. However, the second part of the

JACC VOL. 64, NO. 25, 2014

Hannan et al.

DECEMBER 30, 2014:271726

CABG and PCI Outcomes for Proximal LAD

F I G U R E 1 Kaplan-Meier Survival Curves

DES

CABG

1.00
0.99
0.98
0.97
0.96
0.95
0.94
0.93
0.92
0.0

B
Free From
Mortality/MI/Stroke (%)

Free From Death (%)

0.5

1.0

1.5

2.0

2.5

1.00
0.98
0.96
0.94
0.92
0.90
0.88

3.0

0.0

0.5

1.0

Years

Free From
Revascularization (%)

1.5

2.0

2.5

3.0

Years
1.00
0.98
0.96
0.94
0.92

0.90
0.88
0.86
0.0

0.5

1.0

1.5

2.0

2.5

3.0

Years

Kaplan-Meier survival curves present (A) freedom from death, (B) freedom from mortality, myocardial infarction (MI), and/or stroke, and (C)
freedom from repeated revascularization for propensity-matched coronary artery bypass graft (CABG) and drug-eluting stent (DES) patients
with single-vessel proximal left anterior descending disease during 3-year follow-up.

AUC in this document, which discusses the preferred

5,340 of 6,064 (88%) of all patients who underwent

method when revascularization is indicated, does

revascularization for isolated LAD disease received

not rate CABG surgery versus PCI for patients with

DES. When the 5,340 DES patients were propensity

single-vessel PLAD disease (41).

matched to the 724 CABG surgery patients, we were

As noted earlier, a total of 17 studies from 9 RCTs

able to match 715 CABG surgery patients to 715 DES

examined relative outcomes for CABG surgery and

patients, such that the 2 groups of patients were

PCI in patients with isolated PLAD disease (1632). A

extremely similar with regard to the available patient

meta-analysis of these studies by Kapoor et al. (48)

risk factors contained in the registries. We found that

found no differences in survival at 30 days, 1 year,

there were no statistically signicant differences be-

or 5 years in patients treated with CABG surgery

tween CABG surgery and DES for patients who were

versus patients treated with PCI. There were also no

followed for a median of 2.5 years. However, CABG

differences in the rates of MI. However, the need for

surgery patients did have signicantly lower rates of

repeat revascularization was signicantly lower after

repeat revascularization (AHR: 0.54; 95% CI: 0.36 to

CABG (at 5 years: 7.3% vs. 33.5%) (48). Furthermore, 2

0.81). These ndings remained the same (no signi-

RCTs that compared the use of bare-metal stents with

cant differences for mortality and mortality, MI,

a left internal mammary artery graft found no dif-

and/or stroke, and signicantly lower rates of repeat

ferences in death or MI outcomes (49,50). However,

revascularization for CABG surgery patients) when

all these RCTs were old, and only 1 was new enough

the matched pairs were restricted to patients without

to include patients who underwent PCI with DES.

previous MIs. Also, it should be noted that all but

Clearly, there is a need to compare outcomes for these

19 of the 715 CABG patients in the matched analysis

patients in the DES era.

had left internal mammary artery grafts. Of these

Our observational study found that in New York

19 patients, 15 received saphenous vein grafts and the

between January 1, 2008 and December 31, 2010,

other 4 received other arterial conduits. A total of

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CABG and PCI Outcomes for Proximal LAD

DECEMBER 30, 2014:271726

374 (52.3%) of the CABG patients underwent an off-

ascertainment of chronic obstructive pulmonary dis-

pump procedure.

ease for CABG as a result of chest x-rays and arterial

STUDY LIMITATIONS. There were a few limitations to

blood gases, and a higher ascertainment of cerebro-

the study. First, it was an observational study, and

therefore, it was subject to selection bias in comparison to the results from RCTs. We attempted

vascular disease for CABG as a result of carotid artery

ultrasounds.

CONCLUSIONS

to minimize any bias by using the best available

methods to propensity match patients on the basis of

In conclusion, most patients with isolated proximal

numerous patient characteristics. We were able to

LAD disease undergo PCI. Despite the fact that cur-

show that after propensity matching, the prevalence

rent guidelines have a stronger rating for CABG (IIa

of patient risk factors for the 2 treatments were very

vs. IIb) for these patients, there were no differences

similar. Furthermore, we adjusted for the remaining

between CABG and DES in mortality or mortality, MI,

differences in the prevalence of patient risk factors

and/or stroke, although it is important to note that

between CABG and DES patients using Cox propor-

CABG patients had signicantly lower repeat revas-

tional hazards models for each outcome. Neverthe-

cularization rates.

less, risk factors related to longer term mortality (e.g.,

cancer and frailty status, bleeding risk, ability to
comply with dual antiplatelet therapy, distal vessel
size, regional left ventricular function) that were not
included in the registries could be distributed unevenly across the 2 types of procedures, which could
introduce bias.
Access to only New York State data for capturing
the 3 clinical outcomes assessed in the study (3-year
mortality, subsequent readmission for MI and/or
stroke, and repeat revascularization) was another
limitation; therefore, we could not capture these
events if they occurred outside of New York State.
To minimize the probability that patients could die or
undergo repeat revascularization out of state, we

ACKNOWLEDGMENTS The authors would like to

thank New York States Cardiac Advisory Committee (CAC) for their encouragement and support
of this study, and Kimberly Cozzens, Rosemary
Lombardo, Cynthia Johnson, and the cardiac surgery
departments and cardiac catheterization laboratories
of the participating hospitals for their tireless efforts
to ensure the timeliness, completeness, and accuracy
of the data submitted.
REPRINTS REQUEST AND CORRESPONDENCE: Dr.

Edward L. Hannan, School of Public Health, State

University of New York, University at Albany, One
University Place, Rensselaer, New York 12144-3456.
E-mail: elh03@health.state.ny.us.

limited the study to only residents of New York State.

Nevertheless, patients could have moved to another
state or country, could have died, been admitted
for an MI or stroke, or undergone repeat revascularization elsewhere, which would have been missed
by our study. However, there was no reason why there
should be a bias in favor of either type of treatment
with respect to missed patients; an earlier study
demonstrated that there was no bias in this regard (51).
Other limitations to the study included the
inability to identify which deaths were cardiac
deaths, the inability to detect the impact of lesion
characteristics on outcomes, and limiting the study to
PCIs with DES, as well as not including patients who
received bare-metal stents. It should also be noted
that these data reected relative outcomes between
2008 and 2010, and the data might have changed
since then because of the rapid progress of revascularization technology. Also, the follow-up period for
the study was only 3 years, and relative outcomes
might have changed with a longer follow-up period.
Furthermore, it was possible that there was a higher

PERSPECTIVES
COMPETENCY IN MEDICAL KNOWLEDGE:
Although clinical practice guidelines carry a higher
class of recommendation for CABG surgery (Class IIa)
than for catheter-based deployment of DES (Class
IIb), when revascularization is indicated for patients
with ischemia due to signicant stenosis in CAD
isolated to the PLAD, a comprehensive registry in the
state of New York found no differences between these
approaches in either mortality rates or the combined
rates of mortality, MI, and/or stroke, although CABG
was associated with lower rates of repeated
revascularization.
TRANSLATIONAL OUTLOOK: Randomized trials
involving large cohorts are needed to compare the
outcomes of CABG versus DES in patients with singlevessel disease involving the LAD.

JACC VOL. 64, NO. 25, 2014

Hannan et al.

DECEMBER 30, 2014:271726

CABG and PCI Outcomes for Proximal LAD

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KEY WORDS CABG surgery, outcomes, PCI,

proximal left anterior descending disease