SYNTAX Trial Data Compare Cost Effectiveness of CABG Versus DES PCI

August 1, 2014—David J. Cohen, MD, et al published final cost-effectiveness results from the SYNTAX trial online ahead of print in Circulation. These data evaluated the cost effectiveness of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus bypass surgery for patients with three-vessel or left main coronary artery disease.

As noted by the investigators, the SYNTAX trial demonstrated that in patients with three-vessel or left main coronary artery disease (CAD), coronary artery bypass graft surgery (CABG) was associated with a lower rate of cardiovascular death, myocardial infarction, stroke, or repeat revascularization compared with DES PCI. However, the long-term cost effectiveness of these strategies is unknown. 

As summarized in Circulation, 1,800 patients with left main or three-vessel CAD were randomized to CABG (n = 897) or DES PCI (n = 903) between 2005 and 2007. Costs were assessed from a United States perspective, and health state utilities were evaluated with the EuroQOL quality-of-life questionnaire. A patient-level microsimulation model based on the 5-year in-trial data was used to extrapolate costs, life expectancy, and quality-adjusted life year [QALY] expectancy over a lifetime horizon. 

The investigators reported that although initial procedural costs were lower with CABG by $3,415 per patient, total hospitalization costs were $10,036 higher per patient. During the next 5 years, follow-up costs were higher with DES PCI because of more frequent hospitalizations, revascularization procedures, and higher medication costs. Over a lifetime horizon, CABG remained more costly than DES PCI, but the incremental cost-effectiveness ratio was favorable ($16,537 per QALY gained) and remained < $20,000 per QALY in most bootstrap replicates.

The investigators found that results were consistent across a wide range of assumptions regarding the long-term effect of CABG versus DES PCI on events and costs; however, in patients with left main disease or a SYNTAX score ≤ 22, DES-PCI was economically dominant compared with CABG, although these findings were less certain. 

The SYNTAX investigators concluded that for most patients with three-vessel or left main CAD, CABG is a clinically and economically attractive revascularization strategy compared with DES PCI. However, among patients with less-complex disease, DES PCI may be preferred on both clinical and economic grounds.