Impact of revascularization strategies versus optimized medical treatment on coronary events related only to revascularized arteries: a target clinical trial emulation approach

BACKGROUND: Traditional assessments of coronary revascularization strategies often rely on long-term composite endpoints that reflect the natural progression of coronary artery disease (CAD) rather than the direct efficacy of the intervention itself. This study sought to evaluate the specific impact of surgical and percutaneous revascularization by analyzing nonfatal myocardial infarction (MI) or death occurring exclusively in the territory of the revascularized coronary artery. METHODS: This retrospective, single-center cohort study utilized data from the MASS (Medicine, Angioplasty, or Surgery Study) registry. Patients with multivessel CAD and documented ischemia were included if they were eligible for all three therapeutic strategies: coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimal medical therapy (OMT). The primary endpoint was a composite of nonfatal MI or death attributable solely to the target revascularized vessel. The follow-up period was five years. RESULTS: Of the 1,695 eligible patients, 572 (33.7%) underwent CABG, 549 (32.4%) PCI, and 574 (33.9%) received OMT. Over the five-year follow-up, 155 revascularized-vessel-related events were recorded. The global log-rank test demonstrated significant differences between the groups (p < 0.001). OMT was associated with significantly lower event-free survival compared to both CABG (p < 0.001) and PCI (p < 0.001), while no significant difference was observed between CABG and PCI (p = 0.346). Revascularization resulted in a relative risk reduction of 46-33% compared to OMT. CONCLUSION: Both surgical and percutaneous revascularization were associated with a lower incidence of vessel-specific clinical events compared to optimal medical therapy over five years. These findings highlight the direct, vessel-specific benefits of revascularization strategies in multivessel CAD. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/study/NCT07362108.