Percutaneous vs. surgical revascularization of non-ST-segment elevation myocardial infarction with multivessel disease: the SWEDEHEART registry

Elmir Omerovic; Truls Råmunddal; Petur Petursson; Oskar Angerås; Araz Rawshani; Sandeep Jha; Kristofer Skoglund; Moman A Mohammad; Jonas Persson; Joakim Alfredsson; Robin Hofmann; Tomas Jernberg; Ole Fröbert; Anders Jeppsson; Emma C Hansson; Göran Dellgren; David Erlinge; Björn Redfors

doi:10.1093/eurheartj/ehae700

Percutaneous vs. surgical revascularization of non-ST-segment elevation myocardial infarction with multivessel disease: the SWEDEHEART registry

Eur Heart J. 2024 Nov 27:ehae700. doi: 10.1093/eurheartj/ehae700. Online ahead of print.

Authors

Elmir Omerovic^{1

2}, Truls Råmunddal^{1

2}, Petur Petursson^{1

2}, Oskar Angerås^{1

2}, Araz Rawshani^{1

2}, Sandeep Jha^{1

2}, Kristofer Skoglund^{1

2}, Moman A Mohammad³, Jonas Persson⁴, Joakim Alfredsson^{5

6}, Robin Hofmann⁷, Tomas Jernberg⁴, Ole Fröbert^{8

9}, Anders Jeppsson^{2

10}, Emma C Hansson^{2

10}, Göran Dellgren^{2

10}, David Erlinge³, Björn Redfors^{1

2}

Affiliations

¹ Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
² Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
³ Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.
⁴ Karolinska Institutet, Department of Clinical Sciences, Danderyd University Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden.
⁵ Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
⁶ Department of Cardiology, Linköping University, Linköping, Sweden.
⁷ Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
⁸ Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
⁹ Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
¹⁰ Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.

PMID: 39601339
DOI: 10.1093/eurheartj/ehae700

Abstract

Background and aims: The long-term outcomes of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and multivessel disease remain debated.

Methods: The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry was used to analyse 57 097 revascularized patients with NSTEMI with multivessel disease in Sweden from January 2005 to June 2022. The primary endpoint was all-cause mortality, encompassing both in-hospital and long-term mortality; the secondary endpoints included myocardial infarction (MI), stroke, new revascularization, and heart failure. Multilevel logistic regression with follow-up time as a log-transformed offset variable and double-robust adjustment with the instrumental variable method were applied to control for known and unknown confounders.

Results: Percutaneous coronary intervention was the primary therapy in 42 190 (73.9%) patients, while 14 907 (26.1%) received CABG. Percutaneous coronary intervention patients were generally older with more prior cardiovascular events, whereas CABG patients had higher incidences of diabetes, hypertension, left main and three-vessel disease, and reduced ejection fraction. Over a median follow-up of 7.1 years, PCI was associated with higher risks of death [adjusted odds ratio (aOR) 1.67; 95% confidence interval (CI) 1.54-1.81] and MI (aOR 1.51; 95% CI 1.41-1.62) but there was no significant difference in stroke. Repeat revascularization was three times more likely to PCI (aOR 3.01; 95% CI 2.57-3.51), while heart failure risk was 15% higher (aOR 1.15; 95% CI 1.07-1.25). Coronary artery bypass grafting provided longer survival within 15 years, especially in patients under 70 years of age, with left main disease or left ventricular dysfunction, though this benefit diminished over shorter time horizons.

Conclusions: Coronary artery bypass grafting is associated with lower risks of mortality, MI, repeat revascularization, and heart failure in patients with NSTEMI, particularly in high-risk subgroups. However, its survival benefit lessens with shorter life expectancy.

Keywords: Coronary artery bypass grafting; Multivessel disease; Non-ST-segment elevation myocardial infarction; Percutaneous coronary intervention; Revascularization.