Coronary artery bypass grafting (CABG) has for decades been considered the gold standard for treating patients with multivessel coronary artery disease (CAD)—a condition where several arteries supplying blood to the heart are blocked.

Earlier studies found that CABG was not only clinically more effective but also cost-effective when compared with percutaneous coronary intervention (PCI), a less invasive procedure that uses stents to open clogged arteries.

With major advances in stent technology and imaging tools, however, the balance between these two approaches appears to have shifted, according to new research led by Stanford Health Policy’s Mark Hlatky, MD, a professor of cardiovascular medicine and lead author of a study just published in the Journal of the American College of Cardiology.

Hlatky and colleagues conducted the international, multi-institution study known as the Fractional Flow Reserve vs. Angiography for Multivessel Evaluation—or the FAME 3 Trial—to compare contemporary CABG and PCI, and re-examine their effects on clinical outcomes, quality of life, cost, and cost-effectiveness. In the randomized FAME 3 study of 1,500 patients with three-vessel CAD, researchers compared these outcomes for patients who received CABG versus those treated with fractional flow reserve (FFR)–guided PCI using the latest generation of stents that slowly release an immunosuppressant drug to prevent the stent from blocking up. They followed patients over a five-year period and projected their likely future outcomes.

Striking Findings

The researchers found that over five years, CABG was about 30% more expensive than PCI. Patients in both groups experienced similar survival, quality of life over five years, and so had similar quality-adjusted life-years (QALYs)—a measure that combines both length and quality of life. However, PCI patients had faster recoveries than CABG patients, giving them a slight edge. Also, patients under 65 returned to work faster, and were more likely to still be working five years later.

Hlatky presented the findings at the annual conference of Transcatheter Cardiovascular Therapeutics in San Francisco, and they were published simultaneously in the Journal of the American College of Cardiology.

The other Stanford co-authors of the study were Victoria Ding, MS, a senior statistician, and Manisha Desai, PhD—both of the Quantitative Sciences Unit at Stanford Medicine—and William Fearon, MD, a professor of cardiovascular medicine at Stanford Medicine and chief of the cardiology section at the VA Palo Alto Health Care System.

When researchers modeled the economic value of each treatment, PCI provided greater overall value—delivering comparable health outcomes at a substantially lower cost. In more than 98% of simulations, PCI was preferred over CABG at the generally accepted willingness-to-pay benchmark of $150,000 per QALY, making it the better option.

“CABG costs a lot more than PCI, but in our study patients who had surgery didn’t live any longer or have better quality of life to justify those higher costs. PCI seems to be significantly more cost-effective than CABG for patients who could have either procedure,” Hlatky said.

In short, the study suggests that modern PCI, guided by fractional flow reserve and using advanced drug-eluting stents, offers equivalent health outcomes at much lower cost than bypass surgery. For patients with multivessel CAD, this means that the less invasive option may now not only be easier on the body—but also on the wallet.

“To me, these results are interesting personally, because I did one of the first comparisons of CABG vs. PCI over 30 years ago, and found CABG to be the more cost-effective option,” said Hlatky. “But both procedures continue to advance, and patients are surviving longer with better quality of life than they did years ago. Over time, PCI has widened its cost advantage over CABG while catching up to it in terms of clinical outcomes, so PCI now provides the best value for treating patients with multivessel coronary disease.”

Hlatky added: “Clinical trials like FAME 3 are the best way to compare both clinical effectiveness and economic value of alternative treatments.”

A study conversation with Hlatky and JACC Senior Advisor David J. Cohen: