{
  "abstract": "Introduction The optimal revascularization strategy for multi-vessel coronary artery disease remains debated despite decades of investigation. Contemporary randomized controlled trials comparing drug-eluting stent percutaneous coronary intervention (DES-PCI) with coronary artery bypass grafting (CABG) have demonstrated short-to-medium-term equivalence in major adverse cardiac events, yet robust long-term data beyond 10 years remain limited. Observational studies are confounded by treatment selection bias, with CABG preferentially allocated to higher-risk anatomical subsets. We aimed to compare 20-year all-cause mortality between DES-PCI and CABG in multivessel coronary artery disease using rigorous propensity score matching to address confounding by indication.Methods We conducted a retrospective observational cohort study of consecutive adults undergoing first coronary revascularization for multivessel disease (≥70% stenosis in ≥2 vessels) at a single tertiary cardiac center between January 2003 and December 2018. Patients received either DES-PCI or isolated CABG. The primary outcome was all-cause mortality, with vital status ascertained through national death registry linkage censored May 2, 2024 (maximum follow-up 20.4 years). To address confounding by indication, we employed 1:1 propensity score matching using a greedy nearest-neighbor algorithm with caliper width 0.2 standard deviations of the logit propensity score. The propensity model incorporated 20 prespecified baseline covariates including demographics, cardiovascular risk factors, comorbidities, left ventricular function, anatomical complexity, and procedural urgency. Covariate balance was assessed using standardized mean differences (SMD <0.10 threshold). Survival was compared using Kaplan-Meier methods with log-rank testing and Cox proportional hazards regression with cluster-robust standard errors. Sensitivity analyses included inverse probability of treatment weighting (IPTW) with doubly robust adjustment and subgroup analyses stratified by procedural urgency.Results Of 11,687 patients undergoing first revascularization (CABG n=6,993; DES-PCI n=4,694), propensity score matching created 2,502 matched pairs with excellent covariate balance (mean absolute standardized mean difference 0.086, maximum 0.318 ( table 1)). Over a median follow-up of 11.46 years for CABG and 6.60 years for DES-PCI, 798 deaths occurred in the matched cohort (CABG 288/2,502 [11.5%] versus DES-PCI 510/2,502 [20.4%]). Kaplan-Meier analysis demonstrated persistent CABG superiority throughout 20-year follow-up: survival at 1 year was 96.0% versus 90.2%, widening to 85.4% versus 73.1% at 20 years (table 2, figure 1), representing an absolute survival advantage of 12.3% (log-rank P<0.001). Cox proportional hazards regression in the matched cohort revealed DES-PCI patients experienced more than twofold mortality risk compared with CABG (hazard ratio 2.211, 95% CI 1.913-2.556, P<0.001, C-index 0.602). This association remained robust across sensitivity analyses: unadjusted model HR 1.873 (95% CI 1.701-2.062), multivariable-adjusted model HR 2.529 (95% CI 2.208-2.896), and inverse probability treatment weighting doubly robust model HR 2.785 (95% CI 2.294-3.390), all P<0.001. Treatment benefit was consistent across procedural urgency categories (elective HR 0.407, 95% CI 0.328-0.505; urgent/emergency HR 0.404, 95% CI 0.328-0.497; interaction P=0.335). Subgroup analyses demonstrated CABG superiority across all predefined patient categories. Time-stratified IPTW analysis revealed strongest benefit at 1-5 years (HR 0.281, 72% reduction), sustained significance through 10 years (HR 0.416), with attenuation beyond 10 years (HR 0.686, P=0.123).Conclusion In this propensity-matched real-world cohort with two-decade follow-up, CABG demonstrated markedly superior long-term survival compared with DES-PCI in patients with multi-vessel coronary disease. Surgical revascularization conferred more than twofold mortality reduction, translating to an absolute 12.3% survival advantage at 20 years. The treatment benefit remained consistent across elective and urgent/emergency settings and proved robust to multiple sensitivity analyses including inverse probability weighting. These findings provide compelling long-term observational evidence supporting current guideline recommendations favoring surgical revascularization in anatomically suitable candidates with multi-vessel disease, particularly those with extended life expectancy. Results should inform shared decision-making regarding optimal revascularization strategy when balancing short-term procedural considerations against long-term survival outcomes.Abstract 189 Table 1Baseline characteristicsAbstract 189 Table 2Survival probability for unmatched and matched cohortsAbstract 189 Figure 1Kaplan meier curves of survival of CABG vs DES-PCI groups",
  "authors": [
    {
      "affiliations": [
        "Royal Papworth Hospital, Cambridge, United Kingdom"
      ],
      "name": "Muhammad Saad Asif"
    },
    {
      "affiliations": [
        "Department of Cardiology, Harefield Hospital, London, United Kingdom"
      ],
      "name": "Tito Kabir"
    },
    {
      "affiliations": [
        "Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom"
      ],
      "name": "Sunil K Bhudia"
    },
    {
      "affiliations": [
        "Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom"
      ],
      "name": "Shahzad G Raja"
    }
  ],
  "title": "189 CABG vs DES-PCI for multivessel cad: 20-year survival from propensity-matched cohort",
  "uid": "01a79aa2-fa82-54c0-b035-b4c56cdc4587"
}