Level 1: Likely reliable evidence
In patients with three-vessel and/or left main coronary artery disease (CAD), percutaneous coronary intervention (PCI) with paclitaxel-eluting stents is equivalent to coronary artery bypass grafting (CABG) for overall mortality and MI rate at 12 months. PCI patients had increased risk for repeat revascularization procedures but a reduced risk of subsequent stroke when compared with CABG patients.

Traditionally, CABG is preferred for multivessel CAD and has been shown to reduce mortality compared with PCI involving stenting in the Stent or Surgery (SOS) trial. However, the SOS trial did not use drug-eluting stents. Recently, the Synergy Between PCI with Taxus and Cardiac Surgery (SYNTAX) trial has compared PCI vs CABG involving paclitaxel-eluting stents in 1,800 patients (mean age 65 years) who had previously untreated three-vessel and/or left main coronary artery disease (N Engl J Med. 2009;360:961-972; available at content.nejm.org
/cgi/content/full/360/10/961, accessed May 12, 2009). At 12 months, there were no significant differences in overall mortality or MI rates. Patients who underwent PCI with paclitaxel-eluting stent had lower rates of stroke (0.6% vs. 2.2%, P =.003, NNT 62) but higher rates of repeat revascularization (13.5% vs. 5.9%, P <.001, NNH 14). Limitations to the trial included differential withdrawal rates (not accounted for in intention-to-treat analysis) and differences in medication management between the two groups.