Surgical Risk and Long-Term Mortality With PCI and CABG in Ischemic Left Ventricular Systolic Dysfunction

Background: Coronary artery bypass grafting (CABG) improves survival compared with optimal medical therapy (OMT) alone in patients with ischemic left ventricular systolic dysfunction (iLVSD), but percutaneous coronary intervention (PCI) did not show clinical benefits in this population. However, the randomized controlled trials (RCT) evaluating these 2 revascularization modalities may differ in terms of baseline surgical risk. The aim is to investigate whether the treatment effects of PCI vs OMT, and of CABG vs OMT, are modified by baseline surgical risk.

Methods: A post hoc analysis of the Revascularization for Ischemic Ventricular Dysfunction – British Cardiovascular Intervention Society 2 (REVIVED-BCIS2) and Surgical Treatment for Ischemic Heart Failure (STICH) RCT comparing PCI and CABG vs OMT, respectively, in patients with iLVSD, was conducted. The main outcome was all-cause mortality. Interaction between randomized treatment and baseline surgical risk, estimated by a modified European System for Cardiac Operative Risk Evaluation (EuroSCORE)-II, was quantified.

Results: A total of 666 participants from the REVIVED-BCIS2 trial and 1200 participants from the STICH trial were included. Participants from the REVIVED-BCIS2 trial were more likely to be in the highest tertile of baseline EuroSCORE-II (40.4% vs 29.4%, respectively; P < .001). In the REVIVED-BCIS2 trial, PCI had a consistent lack of effect on all-cause mortality vs OMT across baseline EuroSCORE-II tertiles (P for interaction = .79). In the STICH trial, CABG reduced mortality consistently vs OMT across baseline EuroSCORE-II tertiles (P for interaction = .64).

Conclusions: In the 2 largest RCT evaluating the impact of revascularization in iLVSD and multivessel coronary disease, the treatment effect of PCI vs OMT, and of CABG vs OMT, was not modified by baseline surgical risk.