"Comparison of Everolimus-Eluting Stents or Bypass Surgery for Multivessel Disease (BEST Trial)". The New England Journal of Medicine. 2015.
Links to original sources: Wiki Journal Post Full Journal Article
In patients with multivessel coronary artery disease, is PCI with everolimus-eluting stents noninferior to CABG in terms of major adverse cardiovascular events?
In patients with multivessel coronary artery disease, PCI with everolimus-eluting stents was not noninferior to CABG with respect to major adverse cardiovascular events at 2 years. Over longer-term follow-up, CABG has a lower rate of major adverse cardiovascular events compared to PCI.
The BEST trial aimed to compare the outcomes of multivessel coronary artery disease treated with PCI using everolimus-eluting stents versus CABG. The trial found that after a median of 4.6 years of follow-up, the rate of major cardiovascular events was higher in the PCI group than in the CABG group. This difference was mainly due to a higher rate of target-vessel revascularization in the PCI group.
Current clinical guidelines recommend CABG as the preferred revascularization strategy for patients with complex coronary lesions and without excessive operative risk.
- Multicenter, prospective, open-label, randomized, noninferiority trial - N=880 patients with multivessel coronary artery disease - PCI with everolimus-eluting stents (n=438) vs. CABG (n=442) - Setting: 27 centers in East Asia - Enrollment: 2008-2013 - Median follow-up: 4.6 years - Primary outcome: composite of death, myocardial infarction, or target-vessel revascularization
- Age ≥18 years - Angiographically confirmed multivessel coronary artery disease suitable for PCI or CABG - Excluded if had significant left main coronary artery disease
- PCI with everolimus-eluting stents - CABG with preference for using the internal thoracic artery for revascularization of the left anterior descending coronary artery
#### Primary Outcomes - At 2 years: primary end point occurred in 11.0% of PCI group and 7.9% of CABG group (absolute risk difference, 3.1 percentage points; P=0.32 for noninferiority) - At median 4.6 years follow-up: primary end point occurred in 15.3% of PCI group and 10.6% of CABG group (hazard ratio, 1.47; P=0.04)
- Composite of death, myocardial infarction, stroke, or any repeat revascularization was higher after PCI than after CABG (19.9% vs. 13.3%; P=0.01) - No significant difference in composite safety end point of death, myocardial infarction, or stroke - Higher rates of any repeat revascularization and spontaneous myocardial infarction after PCI - Stent thrombosis occurred in 1.6% of patients within the PCI group
- Early termination of the trial might have reduced the statistical power. - Crossovers from CABG to PCI may have introduced a bias. - Results from the subgroup analyses should be considered exploratory due to restrictions in sample size. - Use of some medications varied significantly between groups. - Includes only patients of Asian race which could affect generalizability.
The trial was supported by the CardioVascular Research Foundation, Abbott Vascular, and a grant from Korea Healthcare Technology R&D Project, Ministry for Health and Welfare Affairs, South Korea.
Additional details and investigators can be found in the Supplementary Appendix at NEJM.org.