Percutaneous coronary intervention or coronary artery bypass grafting for unprotected left main coronary artery
Ahmed N Mahmoud1, Islam Y Elgendy1, Amgad Mentias2
1Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida.
Insights
Percutaneous coronary intervention (PCI) offers a safe alternative to coronary artery bypass grafting (CABG) for unprotected left main disease in the short term. However, long-term follow-up shows PCI may increase major adverse cardiac events due to higher revascularization rates.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Unprotected left main coronary artery disease poses significant risks.
- Previous trials comparing PCI and CABG have shown conflicting results.
Purpose of the Study:
- To conduct an updated meta-analysis of randomized controlled trials.
- To compare percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease.
Main Methods:
- Systematic review and meta-analysis of six randomized trials.
- Included 4,700 patients with a mean SYNTAX score of 23.
- Evaluated outcomes at short-term, intermediate, and long-term follow-up.
Main Results:
- Short-term: PCI reduced major adverse cardiac and cerebrovascular events (MACCE), myocardial infarction, and stroke.
- Intermediate-term: MACCE rates were similar between PCI and CABG.
- Long-term: PCI was associated with higher MACCE, primarily due to increased revascularization needs.
Conclusions:
- PCI is a viable alternative to CABG for patients with unprotected left main disease and low-to-intermediate SYNTAX scores.
- Long-term outcomes require careful consideration, particularly regarding revascularization rates.
Background:
Recent trials comparing PCI with CABG for unprotected left main disease yielded discrepant evidence.
Objectives:
To perform an updated meta-analysis of randomized trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with unprotected left main coronary artery disease.
Methods:
Randomized trials comparing PCI versus CABG for patients with unprotected left main coronary artery disease were included. Summary estimates risk ratios (RRs) were performed with a DerSimonian and Laird model at short-term, intermediate and long-term follow-up periods (i.e., 30-days, 1-year, and >1-year). Outcomes evaluated were major adverse cardiac and cerebrovascular events (MACCE), all-cause mortality, myocardial infarction, stroke, revascularization and stent thrombosis or symptomatic graft occlusion.
Results:
Six trials with 4,700 patients and a mean SYNTAX score of 23 were included. At short-term follow-up, the risk of MACCE was lower with PCI (RR 0.55, 95% confidence interval [CI] 0.39-0.76) driven by the lower risk of myocardial infarction (RR 0.67, 95% CI 0.46-0.99), and stroke (RR 0.38, 95% CI 0.16-0.90). The risk of MACCE was similar at the intermediate follow-up (RR 1.21, 95% CI 0.97-1.51). At long-term follow-up, PCI was associated with a higher risk of MACCE (RR 1.19, 95% CI 1.01-1.41), due to a higher risk of revascularization (RR 1.62, 95% CI 1.34-1.94), while the risk of all-cause mortality, myocardial infarction, and stroke were similar.
Conclusions:
In patients with unprotected left main coronary disease and low to intermediate SYNTAX score, PCI might be an acceptable alternative to CABG. © 2017 Wiley Periodicals, Inc.
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