Dr. Joshua Jacobi discusses Cabq vs. stent

1. CABG vs. StentCABG vs. Stent
Dr. Joshua A. JacobiDr. Joshua A. Jacobi
June 13June 13thth
, 2005, 2005

2. CABG vs. Medical TxCABG vs. Medical Tx
 VA Cooperative and CASS study each showedVA Cooperative and CASS study each showed
mortality benefit as compared to medical txmortality benefit as compared to medical tx
 More patients were free from angina and tookMore patients were free from angina and took
less antianginal medicationless antianginal medication
 Medical tx at that time was nitrates andMedical tx at that time was nitrates and
propranololpropranolol
 Surgical tx in these studies were vein grafts, noSurgical tx in these studies were vein grafts, no
LIMALIMA’’s and aspirin was not used postops and aspirin was not used postop

3. CABG vs. POBACABG vs. POBA
 In several randomized trials, no mortality benefitIn several randomized trials, no mortality benefit
was seenwas seen
 Retrospective analysis of diabetics in BARIRetrospective analysis of diabetics in BARI
showed mortality benefitshowed mortality benefit
 Significant reduction in need forSignificant reduction in need for
revascularization, less antianginal medicines andrevascularization, less antianginal medicines and
freedom from angina with CABGfreedom from angina with CABG
 No mortality benefit with meta-analysisNo mortality benefit with meta-analysis

4. CABG vs. StentCABG vs. Stent
 SoS trial showed mortality benefit over PCI (8SoS trial showed mortality benefit over PCI (8
cancer deaths in the PCI group)cancer deaths in the PCI group)
 ERACI II showed mortality benefit of PCI overERACI II showed mortality benefit of PCI over
CABG however there was excess mortality inCABG however there was excess mortality in
CABGCABG
 Meta-analysis of CABG vs. stent showed noMeta-analysis of CABG vs. stent showed no
mortality benefit with either strategymortality benefit with either strategy

5. CABG vs. stentCABG vs. stent
 If combined POBA and stent vs. CABG thereIf combined POBA and stent vs. CABG there
was mortality benefit at 5 and 8 yearswas mortality benefit at 5 and 8 years
 Again, CABG reduced the need forAgain, CABG reduced the need for
revascularization and less angina whenrevascularization and less angina when
compared to stentscompared to stents
 There is no data comparing CABG vs. drug-There is no data comparing CABG vs. drug-
eluting stents at this timeeluting stents at this time

6. Study DesignStudy Design
 New York cardiac registry of 37,212 pts CABGNew York cardiac registry of 37,212 pts CABG
and 22,102 pts PCI for multivessel CAD Januaryand 22,102 pts PCI for multivessel CAD January
1, 1997 to December 31, 20001, 1997 to December 31, 2000
 Endpoints were death and revascularizationEndpoints were death and revascularization
 Looked at different anatomical subgroupsLooked at different anatomical subgroups
 Adjusted rates of survival based on severity ofAdjusted rates of survival based on severity of
illnessillness

7. Adjusted variablesAdjusted variables
 DiabetesDiabetes
 Depressed LV function or CHFDepressed LV function or CHF
 Peripheral vascular disease (cerebral, carotid,Peripheral vascular disease (cerebral, carotid,
aortailiac, femoral or popiteal)aortailiac, femoral or popiteal)
 COPDCOPD
 Renal failureRenal failure
 Age, maleAge, male
 ShockShock

8. Baseline CharacteristicsBaseline Characteristics

9. Baseline CharacteristicsBaseline Characteristics

10. RevascularizationRevascularization

11. Hazard Ratio for CABG v. stentHazard Ratio for CABG v. stent

12. Hazard Ratio CABG v. StentHazard Ratio CABG v. Stent

13. Survival in 2 vessel CAD withoutSurvival in 2 vessel CAD without
LAD diseaseLAD disease
Unadjusted Adjusted

14. Survival in 2 vessel disease withSurvival in 2 vessel disease with
proximal LAD diseaseproximal LAD disease
Unadjusted Adjusted

15. Survival with 3 vessel CAD withSurvival with 3 vessel CAD with
proximal LAD diseaseproximal LAD disease
Unadjusted Adjusted

16. LimitationsLimitations
 Retrospective, registry analysis leads to selectionRetrospective, registry analysis leads to selection
bias (sicker pts PCI with 3v CAD)bias (sicker pts PCI with 3v CAD)
 Data could only be collected from New York soData could only be collected from New York so
patients who moved would be lost to followuppatients who moved would be lost to followup
 Data is somewhat outdated in that many patientsData is somewhat outdated in that many patients
now receive drug-eluting stentsnow receive drug-eluting stents
 ICD implantation in pts with depressed LVICD implantation in pts with depressed LV
function probably narrow survival advantagefunction probably narrow survival advantage
CABGCABG

17. CABG vs. StentCABG vs. Stent
Dr. Joshua A. JacobiDr. Joshua A. Jacobi
June 13June 13thth
, 2005, 2005