The SYNTAX trial: CABG superior to PCI in triple-vessel or left main artery disease [Classics Series]

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1. In severe coronary artery disease, CABG is superior to PCI in reducing the need for repeat vascularization

2. CABG should remain the standard of care for severe coronary artery disease, despite being associated with a higher risk of stroke

Original Date of Publication: March 5, 2009

Study Rundown: The SYNTAX trial was the first large, multicentre, randomized controlled trial comparing CABG to PCI in severe coronary artery disease. This non-inferiority trial demonstrated that CABG was superior to PCI in preventing the primary endpoint, and this was driven by a decrease in the need for repeat revascularization. CABG, however, was associated with a significantly higher rate of stroke compared to PCI. Strengths of this study include the fact that it was conducted at 85 centres across North America and Europe and that it assessed all-comers with severe coronary artery disease. Criticisms of the study include the limited follow-up of 12 months and that most study participants were male.

Thus, in patients with severe coronary artery disease, the SYNTAX trial suggests that CABG remain the standard of care, given reduced rate of the primary endpoint at the 12 month mark.

Click to read study in NEJM

Relevant Reading:

1. Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. NEJM 2012;367:2375-2384.
2. Bravata DM, Gienger AL, McDonald KM, et al. Systematic review: The comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery. Ann Intern Med 2007;147(10):703-716.

In-Depth [randomized controlled study]: The SYNTAX trial, published in 2009 in NEJM, sought to determine the optimal mode of revascularization (coronary artery bypass graft or CABG vs. percutaneous coronary intervention or PCI) for patients with severe coronary artery disease; that is, previously untreated triple-vessel or left main artery disease. In this non-inferiority trial, the primary endpoint was a composite of death from any cause, stroke, myocardial infarction, or repeat revascularization in the 12-month period after randomization. A total of 3,075 patients were included in the trial. Of these patients, 1,800 were randomized to either CABG or PCI. For the other 1,275, there was only one suitable treatment option, and they were enrolled in registries for either CABG or PCI. Remarkably, the majority of patients studied were male (78%).

There were no significant differences between the two groups in terms of preprocedural rates of major adverse cardiac or cerebrovascular events. At 12 months, there was a significantly lower rate of the primary endpoint in the CABG group compared to PCI, which was driven by a significant reduction in the need for repeat revascularization. Notably, when compared to PCI, there was a significantly higher rate of stroke in the CABG group.

By Adrienne Cheung, Andrew Cheung, M.D.

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