Updated BEST results: No major difference between EES or CABG for multivessel disease

In patients with multivessel coronary artery disease, the risk of any-cause death, myocardial infarction (MI), or target vessel revascularization (TVR) did not vary according to whether patients underwent percutaneous coronary intervention (PCI) with everolimus-eluting stents (EES) or coronary artery bypass graft (CABG), extended follow-up of the BEST* trial showed.

“[T]here were no significant differences in the rates of major adverse cardiac events, serious composite outcomes, and mortality for PCI compared to CABG,” said study author Dr Jung-Min Ahn from the Asan Medical Center and Ulsan University College of Medicine, Seoul, Korea, who presented the results at TCT 2022.

Participants in this international, prospective, open-label trial were 880 patients** aged ≥18 years (mean age 64.5 years, 70–74 percent male) with symptoms of angina and/or objective evidence of myocardial ischaemia and angiography-confirmed multivessel coronary artery disease***. They were randomized 1:1 to undergo PCI with EES (n=438) or CABG (n=442).

Complete revascularization was achieved in 50.9 and 71.5 percent of patients assigned to PCI and CABG, respectively (p<0.001). In the PCI group, the mean number of stents was 3.4, and total stent length and mean stent diameter were 85.3 and 3.1 mm, respectively. In the CABG group, the total number of vessels grafted was 3.1, and 99.3 and 64.3 percent, respectively, underwent left internal mammary artery grafting and off-pump surgery, respectively.

Initial analysis after a median 4.6-year follow-up period showed a greater incidence of the primary composite of death, MI, or TVR among patients assigned to PCI compared with CABG (15.3 percent vs 10.6 percent; hazard ratio [HR], 1.47, 95 percent confidence interval [CI], 1.01–2.13; p=0.04). [N Engl J Med 2015;372:1204-1212]

In the present extended follow-up at a median 11.8 years, the primary composite outcome did not significantly differ between patients assigned to PCI or CABG (34.5 percent vs 30.3 percent; HR, 1.18, 95 percent CI, 0.88–1.56; p=0.26). [TCT 2022, session Late-Breaking Clinical Science in Coronary Artery Disease: Session V; Circulation 2022;doi:10.1161/CIRCULATIONAHA.122.062188]

While the findings were generally consistent across subgroups, the risk of the primary endpoint was increased with PCI vs CABG in patients with diabetes (42.9 percent vs 31.7 percent; HR, 1.52; p=0.007), though between-group outcomes were comparable in patients without diabetes (28.7 percent vs 29.3 percent; HR, 0.97; p=0.79). All-cause death risk was comparable between groups in patients with diabetes (26.0 percent vs 27.4 percent; HR, 0.96; p=0.87).

The incidence of the safety composite of death, MI, or stroke also did not significantly differ between patients in the PCI and CABG groups (28.8 percent vs 27.1 percent; HR, 1.07, 95 percent CI, 0.75–1.53; p=0.70), nor did any-cause death (20.5 percent vs 19.9 percent; HR, 1.04, 95 percent CI, 0.65–1.67; p=0.86).

Repeat revascularization was more common among patients assigned to PCI vs CABG (22.6 percent vs 12.7 percent; HR, 1.92, 95 percent CI, 1.58–2.32; p<0.001), as was spontaneous MI (7.1 percent vs 3.8 percent; HR, 1.86, 95 percent CI, 1.06–3.27; p=0.03), though neither translated to a greater mortality risk, noted the authors. The composite of death, MI, stroke, or any repeat revascularization was also comparable between groups (44.3 percent vs 35.1 percent; HR, 1.36, 95 percent CI, 1.14–1.63; p<0.001).

Intravascular ultrasound (IVUS) was utilized in 71.8 percent of patients who underwent PCI. The incidence of the primary endpoint was higher among patients who underwent PCI without IVUS compared with CABG (44.3 percent vs 24.0 percent; p<0.001 [incidence among patients who underwent PCI with IVUS: 22.8 percent]). Any-cause death did not significantly differ between patients who underwent PCI without IVUS vs CABG (24.5 percent vs 15.7 percent; p=0.08 [incidence among patients who underwent PCI with IVUS: 11.6 percent]).

The use of IVUS in a majority of patients undergoing PCI and the default use of second-generation EES may explain the lack of difference in mortality outcomes between groups, said Ahn and co-authors.

“The extended follow-up of the BEST trial provides important long-term insights that could aid in decision-making for the optimal revascularization strategy in patients with multivessel coronary artery disease,” concluded Ahn. Further research is warranted to assess if the outcomes are generalizable to other ethnicities, the co-authors noted.