1. The project described herein is supported by Award Number RC2HL101489 from the National Heart, Lung, and Blood Institute The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health This award has been issued under the American Recovery and Reinvestment Act of 2009. Composite Analysis of 189,793 Medicare Patients with Multivessel Coronary Disease Demonstrates a Long-Term Advantage for CABG Compared to Percutaneous Stent Placement The authors have no pertinent conflicts of interest or other disclosures. Fred H. Edwards MD, David M. Shahian MD, Maria V. Grau-Sepulveda MD MPH, Frederick L. Grover MD, John E. Mayer MD, Sean M. O’Brien PhD, Elizabeth DeLong PhD, Eric D. Peterson MD MPH, Charles McKay MD, Cynthia M. Shewan PhD, Richard E. Shaw PhD, Kirk Garratt MD, George Dangas MD, John C. Messenger MD, Lloyd W Klein MD, Jeffrey Popma MD, William S. Weintraub MD

2. CONFLICTS ASCERT PI

3. APPROACH  Overview  Statistical Methods  Comparative Analysis  Conclusions

4. Patient Population  2004-2007 coronary revascularization  Medicare age group (average age 74 years)  2 or 3 vessel disease  Exclusions : Single-vessel or Left main disease Emergency procedures MI within 7 days of revascularization Previous CABG Significant valvular disease

5. Methods  Match clinical records to MedPAR records  Calculate propensity score for all patients  Conduct inverse probability weighting (IPW)  Compare event curves in balanced Rx groups

6. CMS MedPAR Patients N =208,537 STS N =393,696 ACC

7. 189,793 Total

8. Patient Characteristics

11. COMPOSITE  Stroke  Myocardial Infarction  All-cause Mortality Readmission with MI (ICD-9 code: 410.x1) Readmission with Stroke (ICD-9 codes: 436.x1, 433.x1, 434.x1)

12. CABG PCI Composite days Event-free RR =.81 Event-free advantage = 19%

13. Stroke days Stroke-free RR = 1.43 Stroke-free advantage = 43% CABG PCI

14. RR =.49 MI-free advantage = 51% CABG PCI Myocardial Infarction days MI-free

15. Comparative Survival days survival RR =.79 Survival advantage = 21%CABG PCI

16. Clinical Subgroups  Age  Number of diseased vessels  Gender  Ejection Fraction  Renal Function  Diabetes

18. DIABETIC POPULATION Survival Years % Survival RR = 0.70

19. DIABETIC POPULATION Composite Years % Event-free RR = 0.73

20. Conclusions  Favoring CABG :  MI (RR = 0.49)  Survival (RR = 0.79)  Composite of stroke, MI, and death (RR = 0.81)  Favoring PCI :  Stroke (RR = 1.43) 4 years after revascularization :

21. Conclusions ASCERT FREEDOM SoS SYNTAX

22. Conclusions  CABG is associated with improved long- term survival and MI rates compared to PCI  PCI is associated with better stroke rates compared to CABG  A Heart Team approach is essential to fully inform patients and optimize care In context with other recent studies :