PCI a reasonable alternative to CABG in elderly, finds SYNTAXES trial

Revascularization with PCI might be as good as CABG surgery in elderly patients with complex coronary artery disease, including multivessel and left main disease, according to the long-term follow-up from the SYNTAX Extended Survival (SYNTAXES) trial, published this month in JACC.

At 10 years, the rates of all-cause mortality were similar between the two revascularization strategies among patients aged 70 years and older, and at 5 years, patients treated with PCI had comparable rates of major adverse cardiovascular and cerebrovascular events (MACCE) as those treated surgically.

These results are important because a previous analysis at 5 year follow-up of SYNTAX, there was no significant difference in the risk of death between surgery and PCI with a first-generation paclitaxel-eluting stent and while there was a thought that mortality curves will diverge and favour CABG in long-term, this followup has shown that PCI was still comparable to surgery.

The SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial randomized patients with 3-vessel or left main (LM) coronary artery disease (CAD) to coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI). Major adverse cardiac or cerebrovascular events (MACCE) at 12 months were significantly higher with PCI driven by repeat revascularization, whereas death and myocardial infarction (MI) were similar between groups.

Among 575 elderly patients, 10-year mortality and 5-year MACCE were similar between PCI and CABG. Importantly, QOL at 5 years with the Seattle Angina Questionnaire was also similar between groups.

Following the SYNTAX trial (published in 2009), durability and outcomes of PCI have improved, as has our understanding of benefits from a particular revascularization strategy. It is important to understand these changes over the last 14 years. The 1-year results found that CABG was better than PCI for reducing the risk of MACCE, a benefit that was driven by a higher rate of revascularization with PCI. The 5-year results confirmed those early findings, with investigators reporting higher rates of MI and revascularization in the PCI-treated patients.

The impact of developments in contemporary PCI on patients with MVD was evaluated in the SYNTAX II trial. This all-comers, open-label study evaluated a strategy of using SYNTAX scores, physiology-guided revascularization, newer bioresorbable-polymer DES, IVUS-guided PCI, contemporary CTO techniques, and guideline-directed medical therapy. Overall, 454 patients were included and showed significantly improved 2-year MACCE compared with a predefined historical PCI cohort from the SYNTAX-I trial and similar outcomes to a historical SYNTAX-I CABG cohort.

The 10-year results of SYNTAX were presented just 2 years ago and showed comparable all-cause mortality among patients treated surgically and those treated with PCI. There also were no significant differences in mortality between treatments for patients with multivessel disease and for those with left main CAD.

In terms of quality of life at 5 years, SYNTAXES showed that health status was similar between the PCI and the CABG groups, with patients reporting comparable angina frequency, physical limitations, treatment satisfaction, and overall quality of life.

In terms of how these results may shape practice, authors emphasize individualized care, highlighting the retooled SYNTAX score, known as SYNTAX II 2020, for predicting the risk of death at 10 years (and MACCE at 5 years) in patients eligible for PCI or CABG surgery.

Ravi Hira, MD (Pulse Heart Institute, Tacoma, WA), who wrote an editorial accompanying the study, points out that elderly patients are excluded from most randomized trials but says the baby-boomer generation has sparked a rise in the number of patients with multivessel CAD.

"Moving forward, interventional cardiologists will need to grow their repertoire for contemporary PCI to provide a legitimate alternative to CABG for patients with increasingly complex CAD. This needs to be offered at their own center or via referral to centers of excellence", concludes Hira.

Source: JACC Interventions: J Am Coll Cardiol. 2021 Jun, 77 (22) 2761–2773