Abstract
BACKGROUND: Randomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality. OBJECTIVE: To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population. DESIGN: Observational treatment comparison using propensity score matching and Cox proportional hazards models. SETTING: United States, 1992 to 2008. PATIENTS: Medicare beneficiaries aged 66 years or older. INTERVENTION: Multivessel CABG or multivessel PCI. MEASUREMENTS: The CABG-PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up. RESULTS: Among 105 156 propensity score-matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P ≤ 0.002 for each) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-years (range, -0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI. LIMITATION: Treatments were chosen by patients and physicians rather than being randomly assigned. CONCLUSION: Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.