The Great Revascularization Strategy Debate: Coronary Artery Bypass Graft or Percutaneous Coronary Intervention?

December 30, 2019

Patients with acute heart failure often require immediate treatment to restore optimal heart function. The 2 primary methods of revascularization are coronary artery bypass graft and percutaneous coronary intervention, but the preferred strategy for use in these patients requires clarification due to risk.

Heart failure (HF), which affects about 26 million people worldwide, can be caused by hypertension, heart valve disorders, and exposure to toxins, among others. The principal cause, however, is usually coronary artery disease (CAD), at 50% of cases. Revascularization is often used to restore optimal heart function.

Acute HF (AHF) can throw a wrench into those plans, especially because its symptoms can appear suddenly and require treatment just as quickly. Clinical outcomes in these patients are often improved through early revascularization, and according to the authors of a recent study in the journal Heart, “current guidelines recommend an immediate invasive strategy, with intent to perform revascularization.” The preferred strategy for use in these patients, however, requires clarification due to risk.

The 2 primary methods of revascularization are coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI). CABG carries a higher surgical risk and can delay revascularization, while there is greater risk of contrast-induced nephropathy and volume overload with PCI.

The investigators compared mortality after each procedure or discharge as the primary outcome. Their study subjects comprised patients from the Korean Acute Heart Failure Registry who were hospitalized for AHF between March 2011 and February 2014: 590 who had undergone PCI and 127 who had CABG.

Compared with the PCI group, those who underwent CABG were younger, male, and more likely to have comorbid diabetes. Upon hospitalization, they also had lower blood pressure and left-ventricular ejection fraction.

For the primary outcome of mortality, 7.9% of patients who underwent CABG died compared with 8.1% of the PCI group; the median follow-up for all-cause death was 1462 versus 1368 days, respectively; and there were 81 (95% CI, 56-113) deaths per 1000 patient-years compared with 131 (95% CI, 114-149). More patients were also rehospitalized for cardiovascular problems in the PCI group than in the CABG group—205 (95% CI, 178-235) and 144 (95% CI, 102-198) per 1000 patient-years, respectively—and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers were prescribed more often upon discharge.

Overall, there was a 40% lower rate of long-term death over 4 years in the CABG group than the PCI group.

“There was a trend favoring CABG over PCI across all clinically relevant outcomes we evaluated,” the study authors noted. “This might be attributable to the different ability of each revascularization strategy to achieve complete revascularization in extensive CADs.”

Reference

Lee SE, Lee H-Y, Cho H-J, et al. Coronary artery bypass graft versus percutaneous coronary intervention in acute heart failure. Heart. 2020:106(1):50-57. doi: 10.1136/heartjnl-2018-313242.