Unprotected left main revascularization: Percutaneous coronary intervention versus coronary artery bypass. An updated
Luca Testa1, Azeem Latib2, Mario Bollati1
1Dept. of Cardiology, IRCCS Pol S. Donato, Milan, Italy.
Insights
Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) show similar safety and efficacy for unprotected left main disease. Both treatments offer comparable major adverse cardiac events and mortality rates at one and five years.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- The optimal treatment strategy for unprotected left main (UPLM) coronary artery disease, comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), remains a critical clinical question.
- Uncertainty exists regarding the long-term safety and efficacy of both PCI and CABG in managing UPLM disease.
Purpose of the Study:
- To conduct a comprehensive comparative analysis of the safety and efficacy of PCI versus CABG in patients diagnosed with UPLM disease.
- To evaluate the primary composite endpoint of major adverse cardiac events (MACE) and its individual components, as well as target vessel revascularization (TVR).
Main Methods:
- Systematic literature search across major databases (PubMed, CENTRAL, BioMedCentral, mRCT) and congress proceedings up to November 2016.
- Inclusion of 6 randomized controlled trials (RCTs) involving 4717 patients comparing PCI and CABG for UPLM disease.
- Analysis of outcomes including MACE (all-cause death, myocardial infarction, stroke), individual MACE components, and TVR rates at 1-year and 5-year follow-up.
Main Results:
- At 1-year follow-up, PCI and CABG demonstrated comparable rates of MACE, death, and myocardial infarction (MI).
- PCI was associated with a significantly lower rate of stroke but a significantly higher rate of TVR compared to CABG.
- At a median 5-year follow-up, MACE, death, MI, and stroke rates remained similar between PCI and CABG, while PCI continued to show a significantly higher TVR rate.
Conclusions:
- Both PCI and CABG are associated with similar rates of major adverse cardiac events and mortality in patients with UPLM disease at both 1-year and 5-year follow-up.
- While overall outcomes are comparable, significant differences exist in individual endpoints like stroke and TVR between the two treatment modalities over time.
Background:
The optimal treatment of unprotected left main (UPLM) with either PCI or CABG remains uncertain.
Aim:
The purpose of this study was to determine the comparative safety and efficacy of PCI versus CABG in patients with UPLM disease.
Methods:
Search of BioMedCentral, CENTRAL, mRCT, PubMed, major cardiological congresses proceedings and references cross-check (updated November 2016). Outcomes were the rate of MACE [all cause death, MI, stroke], the rates of the individual components of MACE and the rate of target vessel revascularisation (TVR).
Results:
We identified 6 Randomised Controlled Trials totalling 4717 patients allocated to PCI or CABG. At 1 year follow up, PCI and CABG were substantially equivalent with respect to the rates of MACE [PCI 8.5% vs CABG 8.9%, OR 1.02,(0.76-1.36), p = 0.9], death [PCI 5.4% vs CABG 6.6%, OR 0.81,(0.63-1.03),p = 0.08] and MI [PCI 3.4% vs CABG 4.3%, OR 0.80(0.59-1.07), p = 0.14]. Notably, PCI was associated with a significantly lower rate of stroke [PCI 0.6% vs CABG 1.8%, OR 0.36,(0.17-0.79), p = 0.01] and with a significantly higher rate of TVR [PCI 8.7% vs CABG 4.5%, OR 2.00(1.46-2.75), p<0.01]. At a median follow up of 5years, the rates of MACE were similar between the two strategies: PCI 14.6% vs CABG 13.8%, OR 1.02(0.76-1.38), p = 0.89. Likewise, the rates of death [PCI 8% and CABG 7.7%, OR 1(0.77-1.31), P = 0.9], MI [PCI 6.1% vs CABG 5%, OR 1.41(0.85-2.34), P = 0.19, I2 59%], and stroke [PCI 2% vs CABG 2.2%, OR 0.85(0.42-1.81), p = 0.65,] were similar while PCI was associated with a significantly higher rate of TVR [14.5% vs CABG 8.9%, OR 1.73(1.41-2.13), p<0.01].
Conclusion:
In patients with UPLM disease, PCI and CABG are associated with similar rates of MACE and mortality at 1 year as well as after 5 years. Differences can be detected for individual end points at both short and long term FU.
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