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Percutaneous or surgical revascularization in multivessel coronary artery disease: synthesis from SYNTAX

David P. Taggart
DOI: http://dx.doi.org/10.1093/eurheartj/ehu253 2789-2791 First published online: 26 June 2014

This editorial refers to ‘Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final 5-year follow-up of the SYNTAX trial’, by S.J. Head et al., on page 2821

In the current issue of the journal Head and colleagues present the 5-year outcome of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in the cohort of SYNTAX patients with three-vessel coronary artery disease (CAD).1 They report a number of important clinical findings, of which the most significant is that CABG offered a marked reduction in absolute mortality (by 5.4%), myocardial infarction (by 7.3%), and the need for repeat revascularization (by 12.8%). The benefits of CABG increased with increasing complexity of CAD so that the survival advantage increased to 9% in those with the most severe disease. These benefits were further magnified in patients with diabetes where the overall absolute reduction in mortality was 10.1%. Finally, as the MACCE (major adverse cardiac and cerebrovascular event) curves, including survival, continue to diverge at 5 years, this implies that these intermediate term results may actually underestimate the real benefits of CABG over an even longer term.

Figure 1

Internal Mammary Artery elutes nitric oxide into the coronary circulation.

These findings are dramatic and raise three important questions. First, are the results likely to be real? Secondly, why are the results so different from the findings in most previous trials of PCI and CABG? Thirdly, are the results likely to be altered by newer generation stents with proven superior performance and safety?

Before answering these questions, it should be acknowledged that the SYNTAX trial is unquestionably the most important randomized trial of PCI and CABG ever to have been conducted, and the investigators should be congratulated on this outstanding achievement.2 It is, however, also important to recognize some obvious …

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