Quality of Life following PCI or CABG

Treatments for patients with multivessel coronary artery disease include percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). At the 1-year followup, the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial found that the rate of composite primary end point (death, myocardial infarction, stroke, or repeat revascularization) was lower with CABG compared with PCI. The largest difference was in the need for repeat revascularization. However, there were no differences between the 2 strategies in the composite end point of irreversible outcomes (death, myocardial infarction, or stroke). Noting that, from a patient’s perspective, other considerations, such as quality of life and relief from angina, may be an important part of the decision-making process in selecting a revascularization strategy, researchers recently conducted a prospective quality-of-life substudy as part of the SYNTAX trial. They reported study results in the New England Journal of Medicine [2011;364(11):1016-1026]. The study was designed to evaluate the effect on quality of life of PCI with the use of drug-eluting stents compared with CABG. Using the Seattle Angina Questionnaire (SAQ) and the Medical Outcomes Study 36-Item Short Form (SF-36), the researchers evaluated health-related quality of life at 1, 6, and 12 months after the procedure. The primary end point was the score on the angina-frequency subscore of the SAQ (SAQ scores range from 0-100, with better health status indicated by higher scores). Between March 2005 and April 2007, the researchers assigned 1800 patients with 3-vessel or left main coronary artery disease to undergo CABG (n=897) or PCI with paclitaxel-eluting stents (n=903). At baseline, there were no significant differences between the 2 groups in characteristics or quality-of-life scores; approximately 12% of the patients reported experiencing angina daily during the month prior to randomization, whereas approximately 20% reported no angina. The response rate for quality-of-life assessments among surviving patients was >90% at all time points (96.2% at baseline, 90.5% at 1 month, 90.3% at 6 months, and 90.5% at 12 months). In both groups, the scores on the SAQ subscales (angina frequency, physical limitation, treatment satisfaction, quality of life, and angina stability) were significantly higher at 6 and 12 months compared with baseline. In the CABG group, the score on the angina-frequency subscale increased to a greater extent compared with the PCI group at 6 and 12 months (P=.04 and P=.03, respectively). The researchers noted that the differences between the groups were small (mean treatment effect of 1.7 points at both 6 and 12 months). At 1 month and 6 months, the proportion of patients free from angina was similar in the 2 groups. At 12 months, the proportion of those free from angina was higher in the CABG group than in the PCI group (73.6% vs 71.6%; P=.05). All other SAQ scores and all SF-36 subscale scores were either higher in the PCI group (mainly at 1 month) or similar in the 2 groups throughout the study period. The researchers cited several limitations to the study, including the short follow-up time after revascularization, the inability to generalize the results to all patients with 3-vessel or left main coronary artery disease, and the fact that there were missing data, which may have biased the results. In conclusion, the researchers summarized the findings: “Among patients with 3-vessel or left main coronary artery disease who were suitable candidates for either PCI or CABG, both strategies resulted in significant relief from angina and improvements in overall health status over the first year of follow-up. At both 6 and 12 months, there was a small but significant reduction in angina frequency with CABG as compared with PCI in the overall population. These symptomatic benefits of CABG were counterbalanced by the more rapid recovery and improved short-term health status achieved with PCI.”