Five-year outcomes of PCI and CABG for multivessel disease: a national population-based study of regional practice

Abstract

Aims: to study how the regional preferences for less invasive multivessel coronary revascularization would adversely affect long-term clinical outcomes.

Methods: a national retrospective cohort study utilizing instrumental variable analysis to estimate the causal effect of revascularization strategy.

England, using national linked Hospital Episode Statistics (HES) with office of national statistic mortality data from 2007 to 2020.

The analysis included 173 771 individuals with complete 5-year follow-up who underwent multivessel revascularization for coronary artery disease. Of this cohort, 63 189 (36.4%) received percutaneous coronary intervention (PCI) and 110 582 (63.6%) received coronary artery bypass grafting (CABG). In total, 37 894 (21.8%) participants were female, and 153 048 (88.2%) were of White ethnicity.

The exposure was the preference between multivessel PCI or CABG. The regional ratio of CABG-to-PCI procedures was used as the instrumental variable.

The primary outcome was all-cause mortality, assessed in-hospital and up to 5 years post-procedure.

Results: the all-cause mortality was 2.1% (n & 3587) in-hospital and 16.4% (n & 28 474) at 5 years. The proportion of patients undergoing CABG varied significantly across regions (25.4–82.3%), demonstrating validity as an instrumental variable. In the primary analysis, CABG was associated with higher in-hospital all-cause mortality vs. PCI [average treatment effect (ATE), 1.1%; 95% confidence interval (CI), 0.6–1.6%] but lower 5-year all-cause mortality (ATE, −5.4%; 95% CI, −7.0 to −3.7%). Adjusted hazard ratios stratified by quartiles of regional CABG-to-PCI ratios showed an increase in in-hospital mortality but a decrease in 5-year mortality as the proportion of CABG increased.

Conclusion: regional preferences for revascularization with multivessel PCI result in lower in-hospital all-cause mortality, a key quality metric, but worse long-term outcomes for individuals with multivessel coronary artery disease.

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Identifiers

ORCID for Nick Curzen: orcid.org/0000-0001-9651-7829

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