CABG and PCI Comparison in Community-Based CKD Population
CABG and PCI Comparison in Community-Based CKD Population
We identified 22,361 patients who underwent initial multivessel coronary revascularization between January 1996 and December 2008 (Figure 1). The proportion of patients receiving CABG as initial revascularization decreased steadily from 94% in 1996 to a nadir of 49% in 2005, and these proportions were consistent across eGFR categories (data not shown). The proportion of PCI patients receiving a drug-eluting stent rose sharply in late 2003, with >88% of all PCI patients receiving ≥1 drug eluting stents between 2004 and 2008, consistent across eGFR categories. In patients receiving CABG, 40%, 39%, and 22% had 2, 3, or ≥4 vessels revascularized, respectively. In patients receiving PCI, the exact number of vessels revascularized could be determined in only 26% of patients (with the remainder identified solely as having had a multivessel procedure); of these, 70% had 2 vessels, 22% had 3 vessels, and 8% had ≥4 vessels revascularized.
In our propensity score-matched cohort (C-statistic 0.791), we matched 67% of patients who received a PCI (n = 4,086) to a patient who received a CABG (Figure 1). Overall, 60% of patients had a baseline eGFR ≥60 mL/min per 1.73 m, 25% had an eGFR 45 to 59 mL/min per 1.73 m, and 15% had an eGFR <45 mL/min per 1.73 m. Baseline variables were well balanced in the matched cohort (Table I). In the full cohort, PCI patients were more likely to be female, and to have a history of MI, hypertension, dyslipidemia, depression, liver disease, and lung disease, these patients were also more likely to use angiotensin II receptor blockers, statins, and an antiplatelet agent, whereas CABG patients were more likely to use nitrates at baseline (online Appendix Supplemental Table II).
Median follow-up of surviving CABG patients was 3.9 years (interquartile range [IQR] 2.0–6.5 years); median follow-up of surviving PCI patients was 3.8 years (IQR 2.0–6.4 years). A total of 1202 patients died in the matched cohort during follow-up. Patients with lower baseline eGFR had higher unadjusted 5-year rates of death than patients with preserved eGFR, regardless of the revascularization type (Table II). Compared with PCI, CABG patients had a lower relative hazard of death across levels of baseline eGFR even after adjustment for potential confounders and longitudinal use of postrevascularization cardiovascular medications, although the CI included 1.0 for patients in the lowest eGFR category (Figure 2). Our results were similar in patients with and without diabetes mellitus (Table III).
(Enlarge Image)
Figure 2.
Multivariable-adjusted HRs for specified outcomes comparing CABG to PCI as initial treatment for multivessel coronary artery disease by eGFR category in the matched cohort. Models adjusted for age, sex, race, Hispanic ethnicity, baseline history of acute MI or unstable angina, medications, smoking status, comorbid conditions, dipstick proteinuria, hemoglobin, HDL, LDL, index year, and local health care facility.
A total of 1159 patients in the matched cohort were hospitalized during follow-up for acute coronary syndrome, and patients with eGFR <45 mL/min per 1.73 m had the highest unadjusted rates (Table II). A total of 1271 patients had a repeat revascularization event during follow-up, but despite having the highest rates of hospitalized acute coronary syndrome, patients in the lowest eGFR category did not have higher unadjusted rates of repeat revascularization (Table II).
Compared with PCI, CABG was associated with significantly lower adjusted risks of acute coronary syndrome and repeat revascularization for patients across all categories of baseline eGFR (Figure 2). Results were similar in patients with and without diabetes mellitus (Table III).
Analyses using the full cohort yielded similar results: for the primary outcome of all-cause mortality, the hazard ratio (HR) was 0.85 (95% CI 0.74–1.00) for eGFR ≥60 mL/min per 1.73 m; HR 0.82 (CI 0.68–0.98) for eGFR 45–59 mL/min per 1.73 m; and HR 0.76 (CI 0.64–0.90) for eGFR <45 mL/min per 1.73 m. Results did not materially change in the other sensitivity analyses, which limited the analysis to patients revascularized between 1996 and 2004, stratified by stent-era, or included a time-varying adjustment for subsequent revascularization procedures (data not shown).
Results
We identified 22,361 patients who underwent initial multivessel coronary revascularization between January 1996 and December 2008 (Figure 1). The proportion of patients receiving CABG as initial revascularization decreased steadily from 94% in 1996 to a nadir of 49% in 2005, and these proportions were consistent across eGFR categories (data not shown). The proportion of PCI patients receiving a drug-eluting stent rose sharply in late 2003, with >88% of all PCI patients receiving ≥1 drug eluting stents between 2004 and 2008, consistent across eGFR categories. In patients receiving CABG, 40%, 39%, and 22% had 2, 3, or ≥4 vessels revascularized, respectively. In patients receiving PCI, the exact number of vessels revascularized could be determined in only 26% of patients (with the remainder identified solely as having had a multivessel procedure); of these, 70% had 2 vessels, 22% had 3 vessels, and 8% had ≥4 vessels revascularized.
In our propensity score-matched cohort (C-statistic 0.791), we matched 67% of patients who received a PCI (n = 4,086) to a patient who received a CABG (Figure 1). Overall, 60% of patients had a baseline eGFR ≥60 mL/min per 1.73 m, 25% had an eGFR 45 to 59 mL/min per 1.73 m, and 15% had an eGFR <45 mL/min per 1.73 m. Baseline variables were well balanced in the matched cohort (Table I). In the full cohort, PCI patients were more likely to be female, and to have a history of MI, hypertension, dyslipidemia, depression, liver disease, and lung disease, these patients were also more likely to use angiotensin II receptor blockers, statins, and an antiplatelet agent, whereas CABG patients were more likely to use nitrates at baseline (online Appendix Supplemental Table II).
Primary Outcome: All-cause Mortality
Median follow-up of surviving CABG patients was 3.9 years (interquartile range [IQR] 2.0–6.5 years); median follow-up of surviving PCI patients was 3.8 years (IQR 2.0–6.4 years). A total of 1202 patients died in the matched cohort during follow-up. Patients with lower baseline eGFR had higher unadjusted 5-year rates of death than patients with preserved eGFR, regardless of the revascularization type (Table II). Compared with PCI, CABG patients had a lower relative hazard of death across levels of baseline eGFR even after adjustment for potential confounders and longitudinal use of postrevascularization cardiovascular medications, although the CI included 1.0 for patients in the lowest eGFR category (Figure 2). Our results were similar in patients with and without diabetes mellitus (Table III).
(Enlarge Image)
Figure 2.
Multivariable-adjusted HRs for specified outcomes comparing CABG to PCI as initial treatment for multivessel coronary artery disease by eGFR category in the matched cohort. Models adjusted for age, sex, race, Hispanic ethnicity, baseline history of acute MI or unstable angina, medications, smoking status, comorbid conditions, dipstick proteinuria, hemoglobin, HDL, LDL, index year, and local health care facility.
Secondary Outcomes: Acute Coronary Syndrome and Repeat Revascularization
A total of 1159 patients in the matched cohort were hospitalized during follow-up for acute coronary syndrome, and patients with eGFR <45 mL/min per 1.73 m had the highest unadjusted rates (Table II). A total of 1271 patients had a repeat revascularization event during follow-up, but despite having the highest rates of hospitalized acute coronary syndrome, patients in the lowest eGFR category did not have higher unadjusted rates of repeat revascularization (Table II).
Compared with PCI, CABG was associated with significantly lower adjusted risks of acute coronary syndrome and repeat revascularization for patients across all categories of baseline eGFR (Figure 2). Results were similar in patients with and without diabetes mellitus (Table III).
Sensitivity Analyses
Analyses using the full cohort yielded similar results: for the primary outcome of all-cause mortality, the hazard ratio (HR) was 0.85 (95% CI 0.74–1.00) for eGFR ≥60 mL/min per 1.73 m; HR 0.82 (CI 0.68–0.98) for eGFR 45–59 mL/min per 1.73 m; and HR 0.76 (CI 0.64–0.90) for eGFR <45 mL/min per 1.73 m. Results did not materially change in the other sensitivity analyses, which limited the analysis to patients revascularized between 1996 and 2004, stratified by stent-era, or included a time-varying adjustment for subsequent revascularization procedures (data not shown).
