Prognostic superiority of coronary artery bypass grafting to percutaneous coronary intervention in non-diabetic patients with anatomically complex multivessel coronary artery disease

The rationale for revascularization in patients with stable coronary artery disease (CAD) is to improve prognosis and relieve symptoms. Revascularization may be indicated in flow-limiting coronary stenosis to reduce myocardial ischemia and its adverse clinical manifestations especially for patients with multivessel CAD. Currently, both US and European guideline statements recommend coronary artery bypass grafting (CABG) rather than percutaneous coronary intervention (PCI) for patients with multivessel CAD (1,2). This recommendation is based primarily on the pivotal Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, which randomized 1,800 patients with extensive angiographic left main and 3-vessel CAD to either PCI with first-generation stents, paclitaxel-eluting stents, or CABG (3). The SYNTAX trial showed significantly higher rates in achieving the primary endpoint, which was defined as a composite of major adverse cardiac and cerebrovascular events (MACCEs) including death, myocardial infarction (MI), stroke, and repeat revascularization, in the PCI group at 1 year. By 5 years, these results showed a more significant separation between CABG and PCI groups for cardiac death, MI, repeat revascularization, and MACCEs, which were all significantly in favor of the CABG group (4). Within the 3-vessel CAD subgroup, in patients with a low SYNTAX score (≤22), which is a novel score for anatomical assessment derived from lesion severity and complexity, the incidence of cardiovascular outcome was similar between the PCI group and CABG group. However, in the intermediate SYNTAX scores [23–32] and high SYNTAX scores (≥33), the incidence of a composite of the MACCEs was significantly higher in the PCI group than in the CABG group. This difference was primarily driven by a higher incidence of repeat revascularization.