Comparison of medium-term outcomes obtained with drug-eluting stents and coronary artery bypass grafts in an unselected population of diabetic patients with multivessel coronary disease. Propensity score analysis

The Real-World Cost-Effectiveness of Coronary Artery Bypass Surgery Versus Stenting in High-Risk Patients: Propensity Score-Matched Analysis of a Single-Centre Experience

BACKGROUND

There are limited economic evaluations comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease (MVCAD) in contemporary, routine clinical practice.

OBJECTIVE

The aim was to perform a cost-effectiveness analysis comparing CABG and PCI in patients with MVCAD, from the perspective of the Australian public hospital payer, using observational data sources.

METHODS

Clinical data from the Melbourne Interventional Group (MIG) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries were analysed for 1022 CABG (treatment) and 978 PCI (comparator) procedures performed between June 2009 and December 2013. Clinical records were linked to same-hospital admissions and national death index (NDI) data. The incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided were evaluated. The propensity score bin bootstrap (PSBB) approach was used to validate base-case results.

RESULTS

At mean follow-up of 2.7 years, CABG compared with PCI was associated with increased costs and greater all-cause mortality, but a significantly lower rate of MACCE. An ICER of $55,255 (Australian dollars)/MACCE avoided was observed for the overall cohort. The ICER varied across comparisons against bare metal stents (ICER $25,815/MACCE avoided), all drug-eluting stents (DES) ($56,861), second-generation DES ($42,925), and third-generation of DES ($88,535). Moderate-to-low ICERs were apparent for high-risk subgroups, including those with chronic kidney disease ($62,299), diabetes ($42,819), history of myocardial infarction ($30,431), left main coronary artery disease ($38,864), and heart failure ($36,966).

CONCLUSIONS

At early follow-up, high-risk subgroups had lower ICERs than the overall cohort when CABG was compared with PCI. A personalised, multidisciplinary approach to treatment of patients may enhance cost containment, as well as improving clinical outcomes following revascularisation strategies.

Comparing mortality between coronary artery bypass grafting and percutaneous coronary intervention with drug-eluting stents in elderly with diabetes and multivessel coronary disease

Coronary artery disease is a critical issue that requires physicians to consider appropriate treatment strategies, especially for elderly people who tend to have several comorbidities, including diabetes mellitus (DM) and multivessel disease (MVD). Several studies have been conducted comparing clinical outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in patients with DM and MVD. However, elderly people were excluded in those clinical studies. Therefore, there are no comparisons of clinical outcomes between CABG and PCI in elderly patients with DM and MVD. We compared all-cause mortality between PCI with drug-eluting stents (DES) and CABG in elderly patients with DM and MVD. A total of 483 (PCI; n = 256, CABG; n = 227) patients were analyzed. The median follow-up period was 1356 days (interquartile range of 810–1884). The all-cause mortality rate was not significantly different between CABG and PCI with DES groups. The CABG group had more patients with complex coronary lesions such as three-vessel disease or a left main trunk lesion. Older age, hemodialysis, and reduced LVEF were associated with increased long-term all-cause mortality in a multivariable Cox regression analysis. The rate of all-cause mortality was not significantly different between the PCI and CABG groups in elderly patients with DM and MVD in a single-center study.

Comparing mortality and myocardial infarction between coronary artery bypass grafting and drug-eluting stenting in patients with diabetes mellitus and multivessel coronary artery disease: a meta-analysis

INTRODUCTION

We aim to compare the midterm outcomes between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in diabetic patients who had multivessel coronary artery diseases (CAD).

MATERIAL AND METHODS

A comprehensive literature search was conducted to identify the related clinical studies with a follow-up for 1 year at least. The endpoints were death, myocardial infarction, and major adverse cardiac and cerebrovascular events (MACCE).

RESULTS

Finally, the analysis of ten studies involving 5,264 patients showed that patients with CABG had worse baseline characteristics, a higher rate of stable angina pectoris, a higher percentage of triple-vessel disease, higher incidence of chronic total occlusion and a higher SYNTAX score. However, there was no significant difference in mortality between the two groups. Additionally, the rates of myocardial infarction and MACCE were markedly decreased in the CABG group.

CONCLUSIONS

The strategy of CABG is better than PCI for diabetic patients with multivessel CAD. The CABG can significantly reduce the rates of myocardial infarction and MACCE and is comparable in mortality despite the worse baseline characteristics.

Comparing coronary artery bypass grafting with drug-eluting stenting in patients with diabetes mellitus and multivessel coronary artery disease: a meta-analysis

OBJECTIVES

Although drug-eluting stents (DESs) reduce the rate of target vessel revascularization compared with bare-metal stents, the results of DESs for patients with diabetes and multivessel coronary artery disease (CAD) in the DES era are inconsistent. This meta-analysis was undertaken to assess the efficacy and safety of coronary artery bypass grafting (CABG) compared with drug-eluting stent implantation in patients with diabetes mellitus and multivessel coronary artery disease.

METHODS

We conducted a search of Medline, EMBASE from January 2003 to July 2013 by two reviewers independently, using the terms 'coronary artery bypass graft surgery', 'drug-eluting stent', 'sirolimus-eluting stent', 'paclitaxel-eluting stent', 'diabetes mellitus' and 'multivessel disease', according to established criteria. Studies comparing CABG with DES in patients with diabetes and multivessel CAD with a minimum follow-up of 1 year were included.

RESULTS

Thirteen studies including 6653 patients with diabetes (3237 who underwent CABG and 3416 who underwent DES implantation) met the selection criteria. The mean follow-up period was 2.9 years (range 1-5). Compared with DES, CABG was associated with a lower risk for major adverse cardiac events (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.46-0.58), driven mainly by a lower risk for repeat revascularization (OR 0.29, 95% CI 0.23-0.35). There was no significant difference with regard to death (OR 0.89, 95% CI 0.75-1.05). Patients in the CABG group had a higher risk for stroke events (OR 2.09, 95% CI 1.45-3.02).

CONCLUSIONS

Percutaneous coronary intervention with DES in patients with diabetes and multivessel CAD is safe, but has a high risk of long-term repeat revascularization. CABG should remain the standard procedure for diabetic patients with multivessel CAD.