The technology of drug eluting stents for percutaneous coronary intervention (PCI) has improved over time with resultant improvements in patient outcomes.  Although prior studies have demonstrated the benefit of surgical coronary artery bypass grafting (CABG) over transcatheter PCI among patients with multivessel coronary artery disease (CAD), these studies did not incorporate newer generation drug-eluting stents.  The multicenter BEST trial randomized 880 patients with multivessel CAD to PCI with an everolimus-eluting stent or to CABG. The primary end point for this non-inferiority study was a composite of death, myocardial infarction, or target-vessel revascularization at 2 years.  The results of the study non-significantly favored CABG at 2 years of follow-up with the primary end-point occurring in 7.9% of the CABG group and 11% of the PCI group.  This advantage achieved statistical significance in longer term follow-up (median 4.6 years, 10.6% vs. 15.3%, HR, 1.47; 95% CI, 1.01 to 2.13; P=0.04).  The majority of this benefit was driven by a higher rate of repeat revascularization among patients treated with PCI; there were no significant differences in the rates of death, overall myocardial infarction or stroke between CABG and PCI.

Conclusions: In this large randomized trial of patients with multi-vessel coronary disease, CABG continued to demonstrate lower rates of adverse events in comparison to patients treated with modern generation drug-eluting stents.  This difference in outcomes was driven by higher rates of repeat revascularization with PCI and not by differences in the rates of myocardial infarction, stroke or death.

Summarized by Hussain Contractor and Steven M. Bradley

• Park SJ, Ahn JM, Kim YH, Park DW, Yun SC, Lee JY, Kang SJ, Lee SW, Lee CW, Park SW, Choo SJ, Chung CH, Lee JW, Cohen DJ, Yeung AC, Hur SH, Seung KB, Ahn TH, Kwon HM, Lim DS, Rha SW, Jeong MH, Lee BK, Tresukosol D, Fu GS, Ong TK.  Trial of everolimus-eluting stents or bypass surgery for coronary disease.  N Engl J Med. 2015 Mar 26;372(13):1204-12.