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Original Investigation
April 8, 2020

Long-term Outcomes in Patients With Severely Reduced Left Ventricular Ejection Fraction Undergoing Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting

Author Affiliations
  • 1Division of Cardiac Anesthesiology, Department of Anesthesiology and Pain Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
  • 2School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
  • 3Institute for Clinical Evaluative Sciences, Ontario, Canada
  • 4Department of Cardiothoracic Surgery, New York Presbyterian Hospital/Weill Cornell Medicine, New York
  • 5Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
JAMA Cardiol. Published online April 8, 2020. doi:10.1001/jamacardio.2020.0239
Key Points

Question  Is there a difference in outcomes for patients with coronary artery disease and severely reduced left ventricular ejection function who undergo revascularization by percutaneous coronary intervention vs coronary artery bypass grafting?

Findings  In this cohort study of 12 113 patients with coronary artery disease, coronary artery bypass grafting was associated with greater long-term survival compared with percutaneous coronary intervention. This survival benefit was observed across different subgroups, including patients with left anterior descending–only disease.

Meaning  The findings suggest that coronary artery bypass grafting should be considered for most patients with severely reduced left ventricular function who require revascularization.

Abstract

Importance  Data are lacking on the outcomes of patients with severely reduced left ventricular ejection fraction (LVEF) who undergo revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

Objective  To compare the long-term outcomes in patients undergoing revascularization by PCI or CABG.

Design, Setting, and Participants  This retrospective cohort study performed in Ontario, Canada, from October 1, 2008, and December 31, 2016, included data from Ontario residents between 40 and 84 years of age with LVEFs less than 35% and left anterior descending (LAD), left main, or multivessel coronary artery disease (with or without LAD involvement) who underwent PCI or CABG. Exclusion criteria were concomitant procedures, previous CABG, metastatic cancer, dialysis, CABG and PCI on the same day, and emergency revascularization within 24 hours of a myocardial infarction (MI). Data analysis was performed from June 2, 2018, to December 28, 2018.

Exposures  Revascularization by PCI or CABG.

Main Outcomes and Measures  The primary outcome was all-cause mortality. Secondary outcomes were death from cardiovascular disease, major adverse cardiovascular events (MACE; defined as stroke, subsequent revascularization, and hospitalization for MI or heart failure), and each of the individual MACE.

Results  A total of 12 113 patients (mean [SD] age, 64.8 (11.0) years for the PCI group and 65.6 [9.7] years for the CABG group; 5084 (72.5%) male for the PCI group and 4229 (82.9%) male for the PCI group) were propensity score matched on 30 baseline characteristics: 2397 patients undergoing PCI and 2397 patients undergoing CABG. The median follow-up was 5.2 years (interquartile range, 5.0-5.3). Patients who received PCI had significantly higher rates of mortality (hazard ratio [HR], 1.6; 95% CI, 1.3-1.7), death from cardiovascular disease (HR 1.4, 95% CI, 1.1-1.6), MACE (HR, 2.0; 95% CI, 1.9-2.2), subsequent revascularization (HR, 3.7; 95% CI, 3.2-4.3), and hospitalization for MI (HR, 3.2; 95% CI, 2.6-3.8) and heart failure (HR, 1.5; 95% CI, 1.3-1.6) compared with matched patients who underwent CABG.

Conclusions and Relevance  In this study, higher rates of mortality and MACE were seen in patients who received PCI compared with those who underwent CABG. The findings may provide insight to physicians who are involved in decision-making for these patients.

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