Evidence based decision making between PCI and CABG

For the last five decades, coronary artery bypass grafting (CABG) surgery has been recommended for patients with unprotected left main (ULM) and multivessel coronary artery disease (MVD). In these populations, CABG reduces mortality compared to medical management. In patients with MVD, several randomized clinical trials established the superiority of CABG over percutaneous coronary interventions (PCI) in terms of hard clinical endpoints.^, In the ULM subgroup of the SYNTAX I trial, comparable outcomes between PCI and CABG were observed at five years. This finding triggered the design and execution of the EXCEL and NOBLE trials that confirmed equipoise in major adverse cardiovascular and cerebral events between PCI and CABG in patients with ULM coronary artery disease (CAD).^,

The accumulation of evidence has allowed to better understand which patients may benefit from a determined revascularization strategy. In the current issue of the Journal, Negreiros de Andrade et al. present a study-level meta-analysis comparing clinical outcomes after PCI and CABG in patients with ULMCAD and MVD. The authors should be commended for the stratified analysis aiming at providing practical information for the cardiovascular community. Based on the current state of evidence we can state that 1) in patients with ULMCAD, PCI can be considered an alternative to CABG in patients with low anatomical complexity, and 2) patients with MVD have better clinical outcomes when treated with CABG. When these two populations were combined, the present meta-analysis showed an early (<30 days) benefit of PCI in terms of mortality and stroke, and long-term advantage of CABG in death and myocardial infarction.

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