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 fare much better with CABG surgery than PCI over long-term follow-up, an analysis of the SYNTAX Extended Survival (SYNTAXES) shows.

Preprocedural physical and mental health status 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, report investigators. In patients with less optimal physical and mental health, there was no difference in mortality between the two revascularization strategies.

“Physicians 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 before randomization—the patient didn’t know whether they were undergoing CABG or PCI—and I think the measures can be integrated into discussions with the heart team.”

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

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

Cardiovascular surgeon Faisal Bakaeen, MD (Cleveland Clinic, OH), who wasn’t involved in the study, cautioned against making too much of the new findings given that they come from a post hoc, subgroup analysis from an extension study. In the main SYNTAX findings, he pointed out, rates of MACCE were significantly higher with PCI than with surgery, a finding driven by higher rates of revascularization at 1 year. Based on those results, the SYNTAX researchers concluded that CABG should remain the standard of care for patients with three-vessel or left main CAD. 

“Even though the findings of the study at hand are interesting, they are far from conclusive,” Bakaeen told TCTMD. “The concept that patients with frailty and poor general physical or mental health may be more 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 the poor physical and mental health scores driven primarily by cardiac symptoms? “If so, they are possibly modifiable with revascularization, and CABG may still be the treatment of choice given the higher rate of complete revascularization that is achievable with CABG and the longevity associated with it,” he said.

Factoring in Mental Health

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

In their new analysis, which was published this week in Circulation, investigators studied 1,656 patients who had complete preprocedural health status assessed with the SF-26. The SF-36 can be divided into two summary measures: the physical component score (PCS) and mental component score (MCS). The mean PCS and MCS were 40.4 and 45.2, respectively, and patients were stratified into three terciles based on the scores, with higher scores reflecting better physical and mental health.  

These individuals—strong mentally and strong physically—do much 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 < 0.001). As a continuous variable, higher PCS was significantly associated with a lower risk of all-cause mortality at 10 years (HR 0.82 per 10-point increase; 95% CI 0.71-0.95). Similarly, all-cause death was 31.1%, 25.1%, and 22.6% among patients with MCS scores ≤ 39.9, > 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).

Investigators observed a significant interaction between revascularization strategy and PCS terciles, with PCI associated with a higher risk of all-cause mortality at 10 years in those who had the highest physical scores (P = 0.033 for interaction). For those with 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 seen between revascularization mode and MCS terciles (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). There was no treatment benefit seen at the lower MCS scores.

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

“If you have poor mental health and poor physical health—you can imagine an older lady, frail, and isolated—PCI can be quite a nice option,” said Serruys. On the other hand, a physically active and mentally healthy individual would be a better candidate for CABG surgery given the better long-term outcomes. “These individuals—strong mentally and strong physically—do much better in terms of mortality with CABG than with PCI,” he said. “The numbers are quite impressive.”

To TCTMD, Bakaeen noted that many patients screened 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 comers in everyday practice,” said Bakaeen.  

The optimal revascularization strategy for patients with three-vessel or left main CAD remains a contentious topic. In the latest American College of Cardiology and American Heart Association (ACC/AHA) revascularization guidelines, CABG surgery was recently downgraded from a prior class 1 recommendation to a class 2b recommendation (level of evidence B) in patients with stable multivessel CAD. Several surgical groups, most notably the American Association for Thoracic Surgery and the Society of Thoracic Surgeons, didn’t endorse the new guidelines because of the downgrade, as well as other issues they had with the document.

While there isn’t as much controversy in the ACC/AHA guidelines for left main CAD—CABG is prioritized over PCI, with PCI recommended only for select patients who have suitable anatomic complexity—members of the European Society of Cardiology’s guideline-writing committee are still reviewing the evidence. That controversy, documented by TCTMD, stems from the European Association for Cardio-Thoracic Surgery withdrawing their support for the left main recommendations after controversies around EXCEL came to light.