Stroke Rates Following Surgical Versus Percutaneous Coronary Revascularization

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with lar...

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Published in:	Journal of the American College of Cardiology Vol. 72; no. 4; p. 386
Main Authors:	Head, Stuart J, Milojevic, Milan, Daemen, Joost, Ahn, Jung-Min, Boersma, Eric, Christiansen, Evald H, Domanski, Michael J, Farkouh, Michael E, Flather, Marcus, Fuster, Valentin, Hlatky, Mark A, Holm, Niels R, Hueb, Whady A, Kamalesh, Masoor, Kim, Young-Hak, Mäkikallio, Timo, Mohr, Friedrich W, Papageorgiou, Grigorios, Park, Seung-Jung, Rodriguez, Alfredo E, Sabik, 3rd, Joseph F, Stables, Rodney H, Stone, Gregg W, Serruys, Patrick W, Kappetein, A Pieter
Format:	Journal Article
Language:	English
Published:	United States 24.07.2018
Subjects:	Aged Coronary Artery Bypass - adverse effects Coronary Artery Bypass - methods Coronary Artery Disease - surgery Drug-Eluting Stents - adverse effects Female Humans Male Middle Aged Outcome and Process Assessment, Health Care Percutaneous Coronary Intervention - adverse effects Percutaneous Coronary Intervention - instrumentation Percutaneous Coronary Intervention - methods Postoperative Complications - diagnosis Postoperative Complications - epidemiology Randomized Controlled Trials as Topic Risk Factors Stroke - diagnosis Stroke - epidemiology Stroke - etiology percutaneous coronary intervention mortality multivessel coronary artery bypass graft left main stroke stenting
ISSN:	1558-3597, 1558-3597
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Abstract	Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with large numbers of patients are required to detect differences in stroke rates between CABG and PCI. This study sought to compare rates of stroke after CABG and PCI and the impact of procedural stroke on long-term mortality. We performed a collaborative individual patient-data pooled analysis of 11 randomized clinical trials comparing CABG with PCI using stents; ERACI II (Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease) (n = 450), ARTS (Arterial Revascularization Therapy Study) (n = 1,205), MASS II (Medicine, Angioplasty, or Surgery Study) (n = 408), SoS (Stent or Surgery) trial (n = 988), SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial (n = 1,800), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) trial (n = 600), FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900), VA CARDS (Coronary Artery Revascularization in Diabetes) (n = 198), BEST (Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease) (n = 880), NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trial (n = 1,184), and EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial (n = 1,905). The 30-day and 5-year stroke rates were compared between CABG and PCI using a random effects Cox proportional hazards model, stratified by trial. The impact of stroke on 5-year mortality was explored. The analysis included 11,518 patients randomly assigned to PCI (n = 5,753) or CABG (n = 5,765) with a mean follow-up of 3.8 ± 1.4 years during which a total of 293 strokes occurred. At 30 days, the rate of stroke was 0.4% after PCI and 1.1% after CABG (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.20 to 0.53; p < 0.001). At 5-year follow-up, stroke remained significantly lower after PCI than after CABG (2.6% vs. 3.2%; HR: 0.77; 95% CI: 0.61 to 0.97; p = 0.027). Rates of stroke between 31 days and 5 years were comparable: 2.2% after PCI versus 2.1% after CABG (HR: 1.05; 95% CI: 0.80 to 1.38; p = 0.72). No significant interactions between treatment and baseline clinical or angiographic variables for the 5-year rate of stroke were present, except for diabetic patients (PCI: 2.6% vs. CABG: 4.9%) and nondiabetic patients (PCI: 2.6% vs. CABG: 2.4%) (p for interaction = 0.004). Patients who experienced a stroke within 30 days of the procedure had significantly higher 5-year mortality versus those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and CABG (41.5% vs. 8.9%, p < 0.001). This individual patient-data pooled analysis demonstrates that 5-year stroke rates are significantly lower after PCI compared with CABG, driven by a reduced risk of stroke in the 30-day post-procedural period but a similar risk of stroke between 31 days and 5 years. The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes. Five-year mortality was markedly higher for patients experiencing a stroke within 30 days after revascularization.
AbstractList	Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with large numbers of patients are required to detect differences in stroke rates between CABG and PCI.BACKGROUNDCoronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with large numbers of patients are required to detect differences in stroke rates between CABG and PCI.This study sought to compare rates of stroke after CABG and PCI and the impact of procedural stroke on long-term mortality.OBJECTIVESThis study sought to compare rates of stroke after CABG and PCI and the impact of procedural stroke on long-term mortality.We performed a collaborative individual patient-data pooled analysis of 11 randomized clinical trials comparing CABG with PCI using stents; ERACI II (Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease) (n = 450), ARTS (Arterial Revascularization Therapy Study) (n = 1,205), MASS II (Medicine, Angioplasty, or Surgery Study) (n = 408), SoS (Stent or Surgery) trial (n = 988), SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial (n = 1,800), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) trial (n = 600), FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900), VA CARDS (Coronary Artery Revascularization in Diabetes) (n = 198), BEST (Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease) (n = 880), NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trial (n = 1,184), and EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial (n = 1,905). The 30-day and 5-year stroke rates were compared between CABG and PCI using a random effects Cox proportional hazards model, stratified by trial. The impact of stroke on 5-year mortality was explored.METHODSWe performed a collaborative individual patient-data pooled analysis of 11 randomized clinical trials comparing CABG with PCI using stents; ERACI II (Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease) (n = 450), ARTS (Arterial Revascularization Therapy Study) (n = 1,205), MASS II (Medicine, Angioplasty, or Surgery Study) (n = 408), SoS (Stent or Surgery) trial (n = 988), SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial (n = 1,800), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) trial (n = 600), FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900), VA CARDS (Coronary Artery Revascularization in Diabetes) (n = 198), BEST (Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease) (n = 880), NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trial (n = 1,184), and EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial (n = 1,905). The 30-day and 5-year stroke rates were compared between CABG and PCI using a random effects Cox proportional hazards model, stratified by trial. The impact of stroke on 5-year mortality was explored.The analysis included 11,518 patients randomly assigned to PCI (n = 5,753) or CABG (n = 5,765) with a mean follow-up of 3.8 ± 1.4 years during which a total of 293 strokes occurred. At 30 days, the rate of stroke was 0.4% after PCI and 1.1% after CABG (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.20 to 0.53; p < 0.001). At 5-year follow-up, stroke remained significantly lower after PCI than after CABG (2.6% vs. 3.2%; HR: 0.77; 95% CI: 0.61 to 0.97; p = 0.027). Rates of stroke between 31 days and 5 years were comparable: 2.2% after PCI versus 2.1% after CABG (HR: 1.05; 95% CI: 0.80 to 1.38; p = 0.72). No significant interactions between treatment and baseline clinical or angiographic variables for the 5-year rate of stroke were present, except for diabetic patients (PCI: 2.6% vs. CABG: 4.9%) and nondiabetic patients (PCI: 2.6% vs. CABG: 2.4%) (p for interaction = 0.004). Patients who experienced a stroke within 30 days of the procedure had significantly higher 5-year mortality versus those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and CABG (41.5% vs. 8.9%, p < 0.001).RESULTSThe analysis included 11,518 patients randomly assigned to PCI (n = 5,753) or CABG (n = 5,765) with a mean follow-up of 3.8 ± 1.4 years during which a total of 293 strokes occurred. At 30 days, the rate of stroke was 0.4% after PCI and 1.1% after CABG (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.20 to 0.53; p < 0.001). At 5-year follow-up, stroke remained significantly lower after PCI than after CABG (2.6% vs. 3.2%; HR: 0.77; 95% CI: 0.61 to 0.97; p = 0.027). Rates of stroke between 31 days and 5 years were comparable: 2.2% after PCI versus 2.1% after CABG (HR: 1.05; 95% CI: 0.80 to 1.38; p = 0.72). No significant interactions between treatment and baseline clinical or angiographic variables for the 5-year rate of stroke were present, except for diabetic patients (PCI: 2.6% vs. CABG: 4.9%) and nondiabetic patients (PCI: 2.6% vs. CABG: 2.4%) (p for interaction = 0.004). Patients who experienced a stroke within 30 days of the procedure had significantly higher 5-year mortality versus those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and CABG (41.5% vs. 8.9%, p < 0.001).This individual patient-data pooled analysis demonstrates that 5-year stroke rates are significantly lower after PCI compared with CABG, driven by a reduced risk of stroke in the 30-day post-procedural period but a similar risk of stroke between 31 days and 5 years. The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes. Five-year mortality was markedly higher for patients experiencing a stroke within 30 days after revascularization.CONCLUSIONSThis individual patient-data pooled analysis demonstrates that 5-year stroke rates are significantly lower after PCI compared with CABG, driven by a reduced risk of stroke in the 30-day post-procedural period but a similar risk of stroke between 31 days and 5 years. The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes. Five-year mortality was markedly higher for patients experiencing a stroke within 30 days after revascularization. Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with large numbers of patients are required to detect differences in stroke rates between CABG and PCI. This study sought to compare rates of stroke after CABG and PCI and the impact of procedural stroke on long-term mortality. We performed a collaborative individual patient-data pooled analysis of 11 randomized clinical trials comparing CABG with PCI using stents; ERACI II (Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease) (n = 450), ARTS (Arterial Revascularization Therapy Study) (n = 1,205), MASS II (Medicine, Angioplasty, or Surgery Study) (n = 408), SoS (Stent or Surgery) trial (n = 988), SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial (n = 1,800), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) trial (n = 600), FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900), VA CARDS (Coronary Artery Revascularization in Diabetes) (n = 198), BEST (Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease) (n = 880), NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trial (n = 1,184), and EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial (n = 1,905). The 30-day and 5-year stroke rates were compared between CABG and PCI using a random effects Cox proportional hazards model, stratified by trial. The impact of stroke on 5-year mortality was explored. The analysis included 11,518 patients randomly assigned to PCI (n = 5,753) or CABG (n = 5,765) with a mean follow-up of 3.8 ± 1.4 years during which a total of 293 strokes occurred. At 30 days, the rate of stroke was 0.4% after PCI and 1.1% after CABG (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.20 to 0.53; p < 0.001). At 5-year follow-up, stroke remained significantly lower after PCI than after CABG (2.6% vs. 3.2%; HR: 0.77; 95% CI: 0.61 to 0.97; p = 0.027). Rates of stroke between 31 days and 5 years were comparable: 2.2% after PCI versus 2.1% after CABG (HR: 1.05; 95% CI: 0.80 to 1.38; p = 0.72). No significant interactions between treatment and baseline clinical or angiographic variables for the 5-year rate of stroke were present, except for diabetic patients (PCI: 2.6% vs. CABG: 4.9%) and nondiabetic patients (PCI: 2.6% vs. CABG: 2.4%) (p for interaction = 0.004). Patients who experienced a stroke within 30 days of the procedure had significantly higher 5-year mortality versus those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and CABG (41.5% vs. 8.9%, p < 0.001). This individual patient-data pooled analysis demonstrates that 5-year stroke rates are significantly lower after PCI compared with CABG, driven by a reduced risk of stroke in the 30-day post-procedural period but a similar risk of stroke between 31 days and 5 years. The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes. Five-year mortality was markedly higher for patients experiencing a stroke within 30 days after revascularization.
Author	Rodriguez, Alfredo E Head, Stuart J Domanski, Michael J Papageorgiou, Grigorios Hlatky, Mark A Hueb, Whady A Mäkikallio, Timo Fuster, Valentin Boersma, Eric Holm, Niels R Farkouh, Michael E Mohr, Friedrich W Kamalesh, Masoor Ahn, Jung-Min Kim, Young-Hak Flather, Marcus Stone, Gregg W Milojevic, Milan Christiansen, Evald H Park, Seung-Jung Daemen, Joost Sabik, 3rd, Joseph F Stables, Rodney H Serruys, Patrick W Kappetein, A Pieter
Author_xml	– sequence: 1 givenname: Stuart J surname: Head fullname: Head, Stuart J email: s.head@erasmusmc.nl organization: Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands. Electronic address: s.head@erasmusmc.nl – sequence: 2 givenname: Milan surname: Milojevic fullname: Milojevic, Milan organization: Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands – sequence: 3 givenname: Joost surname: Daemen fullname: Daemen, Joost organization: Department of Cardiology, Erasmus Medical College, Rotterdam, the Netherlands – sequence: 4 givenname: Jung-Min surname: Ahn fullname: Ahn, Jung-Min organization: Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea – sequence: 5 givenname: Eric surname: Boersma fullname: Boersma, Eric organization: Department of Cardiology, Erasmus Medical College, Rotterdam, the Netherlands – sequence: 6 givenname: Evald H surname: Christiansen fullname: Christiansen, Evald H organization: Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark – sequence: 7 givenname: Michael J surname: Domanski fullname: Domanski, Michael J organization: Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Division of Cardiology, Peter Munk Cardiac Centre and Department of Medicine, Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada – sequence: 8 givenname: Michael E surname: Farkouh fullname: Farkouh, Michael E organization: Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Division of Cardiology, Peter Munk Cardiac Centre and Department of Medicine, Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada – sequence: 9 givenname: Marcus surname: Flather fullname: Flather, Marcus organization: Department of Medicine and Health Sciences, Norwich Medical School University of East Anglia and Norfolk and Norwich University Hospital, Norwich, United Kingdom – sequence: 10 givenname: Valentin surname: Fuster fullname: Fuster, Valentin organization: Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York – sequence: 11 givenname: Mark A surname: Hlatky fullname: Hlatky, Mark A organization: Department of Health Research and Policy, and Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, Stanford, California – sequence: 12 givenname: Niels R surname: Holm fullname: Holm, Niels R organization: Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark – sequence: 13 givenname: Whady A surname: Hueb fullname: Hueb, Whady A organization: Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil – sequence: 14 givenname: Masoor surname: Kamalesh fullname: Kamalesh, Masoor organization: Department of Cardiology, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana – sequence: 15 givenname: Young-Hak surname: Kim fullname: Kim, Young-Hak organization: Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea – sequence: 16 givenname: Timo surname: Mäkikallio fullname: Mäkikallio, Timo organization: Department of Cardiology, Oulu University Hospital, Oulu, Finland – sequence: 17 givenname: Friedrich W surname: Mohr fullname: Mohr, Friedrich W organization: Department of Cardiac Surgery, Herzzentrum Universität Leipzig, Leipzig, Germany – sequence: 18 givenname: Grigorios surname: Papageorgiou fullname: Papageorgiou, Grigorios organization: Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Biostatistics, Erasmus Medical Center, Rotterdam, the Netherlands – sequence: 19 givenname: Seung-Jung surname: Park fullname: Park, Seung-Jung organization: Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea – sequence: 20 givenname: Alfredo E surname: Rodriguez fullname: Rodriguez, Alfredo E organization: Cardiac Unit, Otamendi Hospital, Buenos Aires, Argentina – sequence: 21 givenname: Joseph F surname: Sabik, 3rd fullname: Sabik, 3rd, Joseph F organization: Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio – sequence: 22 givenname: Rodney H surname: Stables fullname: Stables, Rodney H organization: Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom – sequence: 23 givenname: Gregg W surname: Stone fullname: Stone, Gregg W organization: Department of Cardiology, Columbia University Medical Center and Clinical Trials Center, the Cardiovascular Research Foundation, New York, New York – sequence: 24 givenname: Patrick W surname: Serruys fullname: Serruys, Patrick W organization: Department of Cardiology, Imperial College London, London, United Kingdom – sequence: 25 givenname: A Pieter surname: Kappetein fullname: Kappetein, A Pieter organization: Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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Keywords	percutaneous coronary intervention mortality multivessel coronary artery bypass graft left main stroke stenting
Language	English
License	Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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References	30025575 - J Am Coll Cardiol. 2018 Jul 24;72(4):399-401 30452562 - Ann Intern Med. 2018 Nov 20;169(10):JC55 30466529 - J Am Coll Cardiol. 2018 Nov 27;72(21):2679-2680 30466530 - J Am Coll Cardiol. 2018 Nov 27;72(21):2681
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Snippet	Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and...
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SubjectTerms	Aged Coronary Artery Bypass - adverse effects Coronary Artery Bypass - methods Coronary Artery Disease - surgery Drug-Eluting Stents - adverse effects Female Humans Male Middle Aged Outcome and Process Assessment, Health Care Percutaneous Coronary Intervention - adverse effects Percutaneous Coronary Intervention - instrumentation Percutaneous Coronary Intervention - methods Postoperative Complications - diagnosis Postoperative Complications - epidemiology Randomized Controlled Trials as Topic Risk Factors Stroke - diagnosis Stroke - epidemiology Stroke - etiology
Title	Stroke Rates Following Surgical Versus Percutaneous Coronary Revascularization
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