CABG Bests PCI in Patients With Good Physical, Mental Health: SYNTAXES

Patients with multivessel or left main coronary artery disease in optimal physical and mental health have better outcomes with CABG surgery than with PCI during long-term follow-up, an analysis of SYNTAX Extended Survival (SYNTAXES) shows. ).

Physical and mental health status prior to the procedure significantly modified the relative benefits of PCI versus surgery, such that those with the best physical and mental health had a lower risk of death with CABG at 10 years, researchers report . In patients with less than optimal physical and mental health, there was no difference in mortality between the two revascularization strategies.

“Clinicians can judge frailty quite easily because it’s something we see, but the mental part can be unpredictable,” Patrick Serruys, MD, PhD (National University of Ireland, Galway), one of the study’s lead authors, told TCTMD. . “Remember, these were self-reported [physical and mental health] measures prior to randomization (the patient did not know if he would undergo CABG or PCI) and I think the measures can be integrated into discussions with the heart team.”

These self-reported health assessments can provide clinicians with holistic information that will help guide patients toward the best revascularization strategy. The addition of the 36-item Short Form Health Survey (SF-36) can provide an element of precision medicine for patient care, Serruys said.

“Taking into account biomarkers, anatomy and physiology, and taking into account mental and physical health, and being able to have a dialogue with the patient that is semi-quantified where we say, ‘Based on all the parameters that we’ve collected, we think you should go to PCI or surgery’—that’s something that’s still missing from heart team discussions,” he said.

Cardiovascular surgeon Faisal Bakaeen, MD (Cleveland Clinic, OH), who was not involved in the study, cautioned against exaggerating the new findings since they come from a post hoc subgroup analysis of an extension study. In the Main findings of SYNTAX, he noted, MACCE rates were significantly higher with PCI than with surgery, a finding driven by higher rates of revascularization at 1 year. Based on these results, the SYNTAX investigators concluded that CABG should remain the standard of care for patients with three-vessel or left main CAD.

“Although the findings of the study in question are interesting, they are far from conclusive,” Bakaeen told TCTMD. “The concept that patients with frailty and poor physical or mental health in general may be better suited for a less invasive procedure is appealing. However, there are important considerations that come into play that this study cannot address.”

For example, are poor physical and mental health scores primarily due to heart symptoms? “If so, they can possibly be modified by revascularization, and CABG may still be the treatment of choice given the higher rate of complete revascularization that can be achieved with CABG and the longevity associated with it,” he said.

Considering mental health

The SYNTAX study included 1,800 patients with 3-vessel or left main coronary artery CAD who were randomized to PCI with first-generation DES or CABG surgery. Ten-year follow-up of SYNTAXESpublished in 2018, showed no difference in mortality between the two procedures, but long-term data suggested that there was a survival advantage with CABG surgery among patients with left primary CAD.

In their new analysis, published this week in Circulation, the researchers studied 1656 patients who had a complete health status before the procedure evaluated with the SF-26. The SF-36 can be divided into two summary measures: the physical component score (PCS) and the mental component score (MCS). The mean PCS and MCS were 40.4 and 45.2, respectively, and patients were stratified into three tertiles based on scores, with higher scores reflecting better physical and mental health.

These mentally and physically strong individuals do better in terms of mortality with CABG than with PCI. The numbers are quite impressive. Patrick Serruys

At 10 years, all-cause mortality was 33.0%, 23.9%, and 21.9% in patients with PCS values ​​≤ 35.3, > 35.3 to 45.5, and > 45, 5 (log rank P 39.9 to 52.3 and > 52.3 (log rank P = 0.004). Likewise, increases in MCS were associated with a lower risk of mortality when modeled as a continuous variable (HR 0.84 per 10-point increase; 95% CI 0.75-0.93).

The researchers observed a significant interaction between revascularization strategy and PCS tertiles, with PCI associated with increased risk of all-cause mortality at 10 years in those with the highest physical scores (P = 0.033 for interaction). For those in the best physical health (PCS > 45.5), all-cause mortality was 27.3% with PCI versus 16.2% with CABG surgery (P = 0.002), but there was no difference in mortality between PCI and CABG in patients who had lower PCS scores. The same interaction was observed between mode of revascularization and tertiles of MCS (P = 0.015 for interaction). In those with the best mental health (MCS > 52.3), PCI was associated with a higher risk of death compared with surgery (27.8% vs 17.4%; P = 0.005). No treatment benefit was seen in lower MCS scores.

By combining physical and mental health, the 10-year risk of death was significantly increased with PCI in patients with high PCS and MCS scores (30.5% vs 12.2%; P = 0.001). For those with lower PCS and MCS, there was no difference in all-cause mortality between PCI and CABG, nor was there any difference in those with mixed physical and mental health (low PCS/high MCS or high PCS/low MCS).

“If you have physical and mental health issues, you can imagine an older, frail, isolated woman, PCI may be a good option,” Serruys said. On the other hand, a physically active and mentally healthy individual would be a better candidate for CABG surgery due to better long-term results. “These mentally strong and physically strong people do better in terms of mortality with CABG than with PCI,” she said. “The numbers are quite impressive.”

For TCTMD, Bakaeen noted that many patients evaluated for SYNTAX did not qualify for the randomized trial but were instead enrolled in the nested registry, and these patients were more likely to be treated with surgery.

“This study does not look at those patients, and therefore the findings are not generalizable to all stakeholders in daily practice,” Bakaeen said.

The optimal revascularization strategy for patients with 3-vessel or left main coronary artery CAD remains controversial. in the last American College of Cardiology and American Heart Association (ACC/AHA) revascularization guidelines, CABG surgery was recently downgraded from a previous class 1 recommendation to a class 2b recommendation (level of evidence B) in patients with stable multivessel CAD. Several surgical groups, notably the American Association for Thoracic Surgery and the Society of Thoracic Surgeons, did not approve the new guidelines due to degradation as well as other issues they had with the document.

While there is not as much controversy in the ACC/AHA guidelines for CEA of the left main coronary artery (CABG takes precedence over PCI, and PCI is recommended only for selected patients of adequate anatomic complexity), committee members guidelines drafting of the European Society of Cardiology are still reviewing the evidence. That controversy, documented by TCTMD, stems from the European Association for Cardio-Thoracic Surgery withdrawing its support for major leftist recommendations after controversies surrounding EXCEL it came to light.