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10-year follow-up shows no significant difference in all-cause death between PCI and CABG

ESC 2019
Ten-year survival rates of the SYNTAX trial showed no significant difference in all-cause death between percutaneous coronary intervention (PCI) and drug-eluting stents vs coronary artery bypass grafting (CABG) in the overall cohort of patients with coronary artery disease (CAD). However, CABG vs PCI provided a significant survival benefit for patients with three-vessel disease, whereas no treatment difference was seen in all-cause death for patients with left main disease.

The original SYNTAX trial included 1,800 patients with de novo three-vessel and/or left main CAD. Previously reported were 1-year and 5- year survival rates. The SYNTAX Extended survival study is he first and largest randomised trial reporting 10-year all-cause death after PCI with drug-eluting stents vs CABG in patients with three-vessel and left main disease [1]. Patients were randomised to PCI (n=841), trial) or CABG (n=848). This translates into 93.4% and 94.7%, respectively, of the original number of participants in SYNTAX trial, which is remarkably high. A dedicated team including a surgeon and an interventionalist decided if the anatomy was suitable for both CABG and PCI, CABG only, or PCI only. The patients who were amenable to both options constituted the study population for this study. They were further stratified by the presence of left main disease and diabetes mellitus. The investigators also calculated the SYNTAX score for each patient, based on the coronary lesion complexity.

The primary endpoint occurred in 27.0% of PCI patients vs 23.5% CABG patients (HR 1.17; 95% CI 0.97-1.41; P=0.092). Mortality among patients with three-vessel disease was 27.7% with PCI vs 20.6% with CABG (HR 1.41; 95% CI 1.10-1.80, P=0.006). In patients with left main disease this was 26.1% with PCI vs 26.7% with CABG (HR 0.90; 95% CI 0.68-1.20, P=0.47). For patients with diabetes, the outcome was 34.2% for PCI and 32.1% for CABG (HR 1.10; 95% CI 0.80-1.52, P=0.56). It needs to be noted that the SYNTAX score is a useful tool to risk-stratify patients with respect to the optimal revascularisation strategy. The SYNTAX score may aid in distinguishing between complex and less complex cases, which will reflect on treatment choice and may even lead to a paradigm shift in therapy for left main coronary artery disease.

1. Thuijs D. SYNTAXES - Ten-Year Survival after Coronary Artery Bypass Grafting versus Percutaneous Coronary Intervention: The SYNTAX Extended Survival study. FP Number 4197. ESC Congress 2019, 31 Aug-4 Sept, Paris, France.

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