Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease.

BACKGROUND: Numerous studies have compared the outcomes of two competing interventions for multivessel coronary artery disease: coronary-artery bypass grafting (CABG) and coronary stenting. However, little information has become available since the introduction of drug-eluting stents. METHODS: We identified patients with multivessel disease who received drug-eluting stents or underwent CABG in New York State between October 1, 2003, and December 31, 2004, and we compared adverse outcomes (death, death or myocardial infarction, or repeat revascularization) through December 31, 2005, after adjustment for differences in baseline risk factors among the patients. RESULTS: In comparison with treatment with a drug-eluting stent, CABG was associated with lower 18-month rates of death and of death or myocardial infarction both for patients with three-vessel disease and for patients with two-vessel disease. Among patients with three-vessel disease who underwent CABG, as compared with those who received a stent, the adjusted hazard ratio for death was 0.80 (95% confidence interval [CI], 0.65 to 0.97) and the adjusted survival rate was 94.0% versus 92.7% (P=0.03); the adjusted hazard ratio for death or myocardial infarction was 0.75 (95% CI, 0.63 to 0.89) and the adjusted rate of survival free from myocardial infarction was 92.1% versus 89.7% (P<0.001). Among patients with two-vessel disease who underwent CABG, as compared with those who received a stent, the adjusted hazard ratio for death was 0.71 (95% CI, 0.57 to 0.89) and the adjusted survival rate was 96.0% versus 94.6% (P=0.003); the adjusted hazard ratio for death or myocardial infarction was 0.71 (95% CI, 0.59 to 0.87) and the adjusted rate of survival free from myocardial infarction was 94.5% versus 92.5% (P<0.001). Patients undergoing CABG also had lower rates of repeat revascularization. CONCLUSIONS: For patients with multivessel disease, CABG continues to be associated with lower mortality rates than does treatment with drug-eluting stents and is also associated with lower rates of death or myocardial infarction and repeat revascularization.

Off-pump versus on-pump coronary artery bypass graft surgery: differences in short-term outcomes and in long-term mortality and need for subsequent revascularization.

BACKGROUND: Off-pump coronary artery bypass graft surgery (OPCAB) has been performed for many years, but its use is increasing in frequency, and it remains an open question whether OPCAB is associated with better outcomes than on-pump coronary artery bypass graft (CABG) surgery. METHODS AND RESULTS: New York State patients who underwent either OPCAB with median sternotomy (13 889 patients) or on-pump CABG surgery (35 941 patients) between 2001 and 2004 were followed up via New York databases. Short- and long-term outcomes were compared after adjustment for patient risk factors and after patients were matched on the basis of significant predictors of type of CABG surgery. OPCAB had a significantly lower inpatient/30-day mortality rate (adjusted OR 0.81, 95% confidence interval [CI] 0.68 to 0.97), lower rates for 2 perioperative complications (stroke: adjusted OR 0.70, 95% CI 0.57 to 0.86; respiratory failure: adjusted OR 0.80, 95% CI 0.68 to 0.93), and a higher rate of unplanned operation in the same admission (adjusted OR 1.47, 95% CI 1.01 to 2.15). In the matched samples, no difference existed in 3-year mortality (hazard ratio 1.08, 95% CI 0.96 to 1.22), but OPCAB patients had higher rates of subsequent revascularization (hazard ratio 1.55, 95% CI 1.33 to 1.80). The 3-year OPCAB and on-pump survival rates for matched patients were 89.4% and 90.1%, respectively (P=0.20). For freedom from subsequent revascularization, the respective rates were 89.9% and 93.6% (P<0.0001). CONCLUSIONS: OPCAB is associated with lower in-hospital mortality and complication rates than on-pump CABG, but long-term outcomes are comparable, except for freedom from revascularization, which favors on-pump CABG.

Risk index for predicting in-hospital mortality for cardiac valve surgery.

BACKGROUND: Numerous studies have developed a "severity score" or "risk index" for short-term mortality associated with coronary artery bypass graft (CABG) surgery, but very few studies have developed risk indices derived from statistical models to predict outcomes for cardiac valve replacement patients. METHODS: Data from New York's Cardiac Surgery Reporting System in 2001 to 2003 were used to develop statistical models that predict mortality for valve surgery and for valve/CABG surgery. These models were used to develop risk indices based on the type of valve surgery performed and several patient risk factors. The fit of each index was tested by examining the correspondence of expected and observed mortality rates for various risk score ranges using New York data between 1998 and 2000. RESULTS: There were a total of 11 risk factors for valve patients without CABG surgery and 12 risk factors for patients with both valve and CABG surgery. Risk factors represented measures of demographics, type of valve surgery, previous open heart surgery, ventricular function, hemodynamic state, and various comorbidities. Possible variable scores ranged from 0 to 7 in the isolated valve model and 0 to 5 in the valve/CABG model. The highest overall risk scores possible for the two models were 49 for isolated valve surgery and 35 for valve/CABG surgery, and the highest scores observed for any patient were 32 and 26, respectively. CONCLUSIONS: These valve surgery risk indices will enable providers to estimate patients' short-term mortality risk and allow for comparisons of valve surgery outcomes with other regions.

Risk stratification of in-hospital mortality for coronary artery bypass graft surgery.

OBJECTIVES: The purpose of this research was to develop a risk index for in-hospital mortality for coronary artery bypass graft (CABG) surgery. BACKGROUND: Risk indexes for CABG surgery are used to assess patients' operative risk as well as to profile hospitals and surgeons. None has been developed using data from a population-based region in the U.S. for many years. METHODS: Data from New York's Cardiac Surgery Reporting System in 2002 were used to develop a statistical model that predicts mortality and to create a risk index based on a relatively small number of patient risk factors. The fit of the index was tested by applying it to another year (2003) of New York data and testing the correspondence of expected and observed mortality rates for each risk score in the index. RESULTS: The risk index contains a total of 10 risk factors (age, female gender, hemodynamic state, ejection fraction, pre-procedural myocardial infarction, chronic obstructive pulmonary disease, calcified ascending aorta, peripheral arterial disease, renal failure, and previous open heart operations). The score possible for each variable ranges from 0 to 5, and total risk scores possible range from 0 to 34. The highest score observed for any patient was 22, and 93% of the patients had scores of 8 or lower. When the risk index was applied to another year of New York data with a considerably lower mortality rate, the C-statistic was 0.782. CONCLUSIONS: The risk index appears to be a valuable tool for predicting patient risk when applied to another year of New York data. It should now be tested against other risk indexes in a variety of geographical regions.