<P><STRONG>DES, CABG Achieve Similar Long-Term Mortality in Multivessel Disease</STRONG></P> <P><STRONG></STRONG>&nbsp;</P> <P>By Caitlin E. Cox</P> <P>&nbsp;</P> <P>Drug-eluting stents (DES) and coronary artery bypass graft surgery (CABG) offer patients with multivessel coronary artery disease similar mortality benefits at 3-year follow-up, although DES use appears to result in significantly higher revascularization rates, according to registry data published online on April 14, 2008, ahead of print in Circulation.</P> <P>&nbsp;</P> <P>A research team led by Seung-Jung Park, MD, of Asan Medical Center (Seoul, Korea), compiled data on 3,042 patients with multivessel disease who underwent DES placement with sirolimus-eluting or paclitaxel-eluting stents (n=1,547) or bypass surgery (n=1,495). The primary endpoint was all-cause mortality.</P> <P>&nbsp;</P> <P>Crude data pointed towards a mortality benefit for DES, though when adjusted for baseline characteristics, death rates were similar between the 2 groups (table 1). Patient subgroups with diabetes or poor left ventricular function, both of which experienced increased death rates compared with the study population as a whole, also showed no significant difference in mortality between DES vs. CABG.</P> <P>&nbsp;</P> <P>The study did reveal a significant mortality benefit from DES in patients with 2-vessel disease involving the nonproximal left anterior descending artery (HR 0.23; 95% CI, 0.01-0.78). However, patients who underwent DES implantation had significantly higher revascularization rates than those who received CABG (HR 2.81; 95% CI, 2.11-3.75).</P> <P>&nbsp;</P> <P>Dr. Park’s study comes on the heels of data he presented earlier this month in Chicago, IL, at the Society of Cardiovascular and Angiography Interventions-American College of Cardiology (SCAI-ACC/i2) joint summit that focused on patients with left main disease. That study, published online simultaneously March 31, 2008, in the New England Journal of Medicine, also found equivalent mortality for DES and CABG, with an elevated risk of revascularization after DES implantation.</P> <P>&nbsp;</P> <P><STRONG>Weighing the Evidence from Registries, Awaiting Randomized Trials</STRONG></P> <P>&nbsp;</P> <P>In an e-mail communication with TCTMD, Dr. Park said, “Data regarding the long-term outcomes beyond 1 year among patients with multivessel coronary artery disease who underwent DES or CABG is very limited. Our study provides insight for long-term results of DES comparable to CABG, which is somewhat inconsistent with a recent report on the same issue. Therefore, these conflicting issues should be [resolved] by well-controlled, large randomized trials.”</P> <P>&nbsp;</P> <P>Dr. Park was referring to the study published in the January 24, 2008, issue of the New England Journal of Medicine, led by Edward L. Hannan, PhD, of the University of Albany (Albany, NY), which found CABG to be associated with lower 18-month mortality rates compared to DES in a similar patient population.</P> <P>&nbsp;</P> <P>Dr. Park said his study’s findings support “equivalent safety but not comparable effectiveness” of DES compared with CABG. He added that, “considering the preference of many patients for stenting to avoid general anesthesia and major surgery,” DES still provide an alternative treatment strategy for multivessel disease.</P> <P>&nbsp;</P> <P>Gregg W. Stone, MD, of Columbia University Medical Center (New York, NY), agreed that further research is needed. “To really understand the safety and efficacy of drug-eluting stents in patients with multivessel disease, we need to wait for randomized trials,” he said in a telephone interview with TCTMD. Dr. Stone specifically highlighted the FREEDOM trial on diabetics with multivessel disease and SYNTAX, a trial investigating both diabetic and nondiabetic patients who have triple vessel and left main disease.</P> <P>&nbsp;</P> <P><STRONG>Clinical Practice in the “DES Era”</STRONG></P> <P>&nbsp;</P> <P>“I personally believe that we will find some subsets of patients who will do absolutely fine or even better with drug-eluting stents, and we will find some subsets of patients who will do better with bypass surgery still, despite [us being in] the drug-eluting stent era. The devil will be in the details,” Dr. Stone said.</P> <P>&nbsp;</P> <P>He commented that, in concert with earlier findings, Dr. Park’s registry “suggests that patients with multiple, relatively simple on-label type lesions will do fine with drug-eluting stents. I think that patients with very complex lesion morphology who would require 6 or 8 or 10 stents because of diffuse disease, especially if they’re diabetic, probably should still be referred for bypass surgery pending the results of randomized trials.”</P> <P>&nbsp;</P> <P>source：<A href="http://www.tctmd.com">www.tctmd.com</A></P> <P>&nbsp;</P>