Background Data from randomized clinical trials comparing coronary artery bypass grafting ( CABG ) and percutaneous coronary intervention ( PCI ) may not accurately reflect current clinical practice, in which there is off‐label usage of drug‐eluting stents ( DES ). We undertook a prospective registry of coronary revascularization by CABG on‐ and off‐pump and PCI with bare‐metal stents ( BMS s), DES s, or percutaneous transluminal coronary angioplasty ( PTCA ) to determine clinical outcomes. Methods and Results All patients undergoing isolated coronary revascularization in 8 community‐based hospitals were enrolled. Final follow‐up was obtained after 5 years by patient and/or physician contact and the Social Security Death Index. ST ‐elevation myocardial infarction and salvage patients were excluded. Five or more years of follow‐up was obtained on 81.5% (3156) of the eligible patients—968 CABG patients (82.0%) and 2188 PCI patients (81.3%). Overall follow‐up was 63.5±27.9 months (median , 79.7 months). The incidence of initial major adverse cardiac events ( MACE s) at follow‐up for CABG versus PCI was 29.2% versus 41.8% ( P <0.001). Analysis of stent subgroups showed more events with BMS s (equivalent to PTCA alone) compared with DES s. All stents had more events than on‐ or off‐pump CABG groups. Using propensity score–matched groups, the odds ratio for CABG to PCI was 0.69 (95% confidence interval [ CI ], 0.56 to 0.85; P <0.001) for mortality and 0.58 (95% CI , 0.45 to 0.75; P <0.001) for any MACE . Conclusions In the current era of DES and off‐pump surgery, in a community hospital setting, comparable patients undergoing coronary revascularization appear to benefit from improved long‐term survival and reduced MACE with CABG versus PCI .