Feature | March 25, 2015

Heart Bypass Surgery Outperforms New Generation Stents in BEST Trial

Despite stent advances, bypass remains best option for treating multiple narrowed arteries

BEST Trial

March 25, 2015 — Despite the advent of a new generation of stents, patients with multiple narrowed arteries in the heart who received coronary artery bypass grafting fared better than those whose arteries were opened with balloon angioplasty and stents in a study presented at the 2015 American College of Cardiology (ACC) Annual Scientific Session.

The study, called the Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease (BEST) trial, is one of only two randomized controlled trials to compare bypass to angioplasty since the introduction of everolimus-eluting stents, a new generation of drug-eluting stent. These stents emit medication to prevent blood clots and have been shown to be more effective at keeping arteries open. The trial’s findings align with those from the previous study, called Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX).

The findings echo past studies, which have shown patients with multiple narrowed arteries have better outcomes with coronary artery bypass grafting, also known as CABG or heart bypass surgery, than with angioplasty, also known as percutaneous coronary intervention or PCI, a less-invasive option in which a stent is inserted to hold the arteries open.

In the new study, patients receiving angioplasty with the new stents had a 47 percent higher risk of one of the outcomes identified as a primary endpoint in the study: death, heart attack and subsequent procedure to clear blocked arteries, as compared to patients who received bypass. In bypass surgery, a vein or artery from elsewhere in the body is grafted onto a narrowed coronary artery to allow blood to flow to the heart more freely. The study reinforces current guidelines, which recommend bypass surgery for treating patients with substantial narrowing in multiple arteries, a condition known as multivessel coronary artery disease.

“Based on our data, CABG is still the preferred option for multivessel disease,” said Seung-Jung Park, M.D., a cardiologist at Asan Medical Center in Seoul, South Korea, and the study’s lead author. “We had thought that previous trials may have been limited by their use of first-generation drug-eluting stents, but these results show CABG still leads to better outcomes.”

The study included 880 patients treated at 27 hospitals in four countries. All patients had multivessel coronary artery disease and were determined to be equally appropriate candidates for either angioplasty or bypass. Half of the patients were randomly assigned to receive angioplasty with everolimus-eluting stent and half received bypass surgery. Patients were tracked for an average of more than 4.5 years.

“During this relatively long-term follow-up, angioplasty was associated with a significant increase in the incidence of the death, myocardial infarction and target vessel revascularization, a difference that was mainly attributed to the higher rate of target-vessel revascularization in the angioplasty group,” Park said.

Death, heart attack or a subsequent procedure to clear blocked arteries occurred in 15 percent of patients in the angioplasty group and 11 percent of patients in the bypass group. In addition, the researchers found patients receiving angioplasty were twice as likely to need repeat revascularization and more than 1.8 times as likely to have a heart attack as patients who received bypass.

The study was terminated earlier than planned, limiting its statistical power to detect differences in individual outcomes instead of only composite outcomes. The early termination was due to slow enrollment, thought to be a consequence of the rapid spread and increased appeal of a new angioplasty technique called fractional flow reserve during the later part of the study enrollment period.

The angioplasty procedures in the BEST and SYNTAX studies were guided by the medical imaging technique angiography. Fractional flow reserve, by contrast, allows surgeons to more precisely assess the condition of the arteries based on the pressure of blood as it flows through them and has been associated with better outcomes for angioplasty. A new study is currently underway to compare outcomes from bypass to angioplasty using fractional flow reserve in patients with multivessel coronary artery disease.

Because it is a more invasive procedure, heart bypass is generally recommended only for patients with higher-risk narrowing in two or more arteries. Angioplasty is preferred for patients with lower-risk narrowing in one or two arteries.

This study was simultaneously published online in the New England Journal of Medicine at the time of presentation.

For more information: acc.org

Related Content

Mandatory Public Coronary Artery Bypass Grafting Reporting Associated With Better Patient Outcomes
News | Cardiovascular Surgery | April 30, 2018
Mandatory public reporting of coronary artery bypass grafting (CABG) results in Massachusetts was associated with...
Gecko Biomedical Receives CE Mark Approval for Setalum Sealant
News | Cardiovascular Surgery | September 19, 2017
Gecko Biomedical announced it has received CE Mark approval for its Setalum Sealant, allowing the company to market its...
ClearFlow Inc. Announces Positive U.S. Clinical Trial Results
News | Cardiovascular Surgery | September 08, 2017
September 8, 2017 — ClearFlow Inc.
Videos | Cardiovascular Surgery | July 19, 2017
This video educational session, provided in partnership with the American Society of Echocardiography (ASE), is title
Intensive Glycemic Control Program Produces Significant Per-Patient Cost Savings for CABG Surgery
News | Cardiovascular Surgery | May 25, 2017
A new study from Emory University observed a near-20 percent reduction in perioperative complications, a 1.2-day...
Risk of Heart Transplant Rejection Reduced by Desensitizing Patient Antibodies
News | Cardiovascular Surgery | May 23, 2017
The risk of heart transplant rejection can be reduced by desensitizing patient antibodies, according to research...
Scientists Show How Cells React to Injury From Open-Heart Surgery
News | Cardiovascular Surgery | May 04, 2017
Cedars-Sinai Heart Institute investigators have learned how cardiac muscle cells react to a certain type of injury that...
ERACS Session Highlights Need for Standardized Best Practices in Cardiac Surgery
News | Cardiovascular Surgery | May 02, 2017
The recently formed group Enhanced Recovery After Cardiac Surgery (ERACS) hosted an organizing session in Boston on...
ClearFlow Receives Frost & Sullivan New Product Innovation Award for PleuraFlow Technology
News | Cardiovascular Surgery | May 01, 2017
ClearFlow Inc. has received the prestigious 2017 Global Frost & Sullivan Award for New Product Innovation. The...
Edwards Intuity Elite sutureless aortic valve, first implants in Connecticut, WCHN, Western Connecticut Health Network
News | Cardiovascular Surgery | February 16, 2017
Western Connecticut Health Network (WCHN) cardiothoracic surgeons Cary Passik, M.D., and Robert Gallagher, M.D., were...
Overlay Init