Improving long-term outcomes following coronary artery bypass graft or percutaneous coronary revascularisation: results from a large, population-based cohort with first intervention 1995-2004

Objective: To describe recent trends in outcome after first coronary revascularisation in routine clinical practice, with a focus on the influence of co-morbidity, demographics and ethnicity. Design: Historical cohort study. Setting: Leicestershire, UK (resident population 946 000). Patients: All consecutive patients (n = 6068) after first-ever coronary revascularisation by coronary artery bypass graft surgery (CABG, n = 2520) or percutaneous coronary intervention (PCI, n = 3548) in the period between 1995 6 and 2003-4. Outcome measures: Mortality (all-cause and cardiovascular), repeat revascularisation, unplanned readmission, acute myocardial infarction (MI), stroke and the combination of these outcomes. Results: Among inpatients undergoing their first revascularisation, hospital co-morbidity increased significantly between 1995-6 and 2003-4. In contrast, operative outcomes improved, particularly among the PCI patients experiencing a two-year event-free survival of 83% in the latter period (2001-4), compared to just 73% in the earlier period (1995-8). After statistical adjustment for the temporal increase in preoperative co-morbidity and changing patient demographics, the rates of all-cause and cardiovascular mortality were similar after PCI when compared to CABG, generally less than 5% in the first two years following the index procedure. However, the risk of further revascularisation was much higher (10-fold) with index PCI. The adjusted risk for the need for further procedure was lower after PCI with a coronary stent (HR 0.61, 95% CI 0.49 to 0.74), compared to without, a coronary stent. Except for the risk of readmission, outcome was independent of patients' ethnicity, and for women the risk of death was lower (HR 0.73, 95% CI 0.61 to 0.87). Conclusions: On a background of increasingly complex preoperative profile, outcomes after first coronary revascularisation procedure seem to have improved in routine clinical practice since the 1990s, and compare well to those seen in clinical trials. In contemporary, routine clinical practice survival is very similar after CABG or PCI, but rate of further revascularisation procedure remains much higher after PCI, despite increasing use of coronary stenting.