PCI vs CABG: Equal Survival, Lower Cost — FAME 3 (Five-Year Update)
PCI vs CABG: Equal Survival, Lower Cost — FAME 3
(Five-Year Update)
Source: TCT 2025 | JACC,Oct 27 2025
Keynotes:
1. Design: 1,500 patients with three-vessel CAD randomized to FFR-guided PCI vs CABG.
2. Primary outcome (Death + MI + Stroke): No significant difference — 16.0 % (PCI) vs 14.1 % (CABG); HR 1.16 (95 % CI 0.89–1.52); P = 0.27.
3. Mortality: Identical — 7.2 % each.
4. MI & Repeat revascularization: Higher with PCI (~8 % and 16 %) vs CABG (~5 % and 8 %).
5. Cost-effectiveness: PCI ≈ 30 % less expensive ($25.7 K vs $39.9 K); QALY slightly higher (4.05 vs 4.03).
6. Functional recovery: Employment at 5 years = 56 % (PCI) vs 47 % (CABG) → faster recovery and return to work.
7. Interpretation: Modern FFR-guided PCI provides comparable safety and superior economic value for appropriately selected three-vessel patients, while CABG retains advantage for complex anatomy or diabetes.
8. Extended evidence:
• SYNTAX (10 Years): Comparable survival, but CABG fewer MIs and reinterventions in high-complexity disease.
• BEST (≈ 10 Years): No difference in overall mortality; PCI had higher MI and repeat procedures.
• FREEDOM (10 Years, Diabetics): CABG clearly superior for major events.
• (No randomized studies beyond 10 years using modern DES and FFR techniques exist to date.)
9. Take-home: For lower-complexity multivessel CAD, PCI is a safe, cost-effective alternative; CABG remains preferred for high SYNTAX scores and diabetic patients.
(Earlier long-term trials — including the 20-year follow-up from early PCI vs CABG studies such as the Dutch trials and MASS II — provide historical insight but reflect pre-DES technology, making them not directly comparable to today’s FFR-guided or modern DES outcomes.)
