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Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Percutaneous coronary intervention versus cardiac bypass surgery for left main coronary artery disease: A trial
Yicong Ye1, Ming Yang, Shuyang Zhang
1Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
Insights
Coronary artery bypass grafting (CABG) is superior to percutaneous coronary intervention (PCI) for left main coronary artery disease (LM CAD), reducing major adverse cardiac and cerebrovascular events (MACCE). CABG is recommended for complex cases, while PCI suits less complex anatomies.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Recent meta-analyses compare percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery disease (LM CAD).
- Conventional meta-analyses may carry a high risk of false-positive results due to repetitive data analysis.
- Trial sequential analysis (TSA) was employed to provide more reliable comparisons.
Purpose of the Study:
- To compare the efficacy and safety of PCI versus CABG for LM CAD using TSA.
- To confirm or refute conclusions from conventional meta-analyses.
- To evaluate treatment outcomes based on coronary artery complexity.
Main Methods:
- A systematic literature search of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials was conducted.
- Included studies were randomized controlled trials (RCTs) or relevant subgroups comparing PCI and CABG in LM CAD patients.
- The primary outcome was major cardiac and cerebrovascular adverse events (MACCE); TSA was used to analyze the data.
Main Results:
- Six RCTs involving 4700 patients were analyzed.
- PCI was associated with a significantly higher risk of MACCE (RR 1.21) and revascularization (RR 1.61) compared to CABG.
- TSA confirmed that CABG significantly reduces MACCE and revascularization. CABG showed superiority in patients with SYNTAX score >32, while no significant difference was observed for scores 0-32.
Conclusions:
- CABG appears to be a better option than PCI for LM CAD, primarily due to a lower risk of revascularization and reduced MACCE.
- CABG is the preferred treatment for LM CAD patients with high anatomical complexity (SYNTAX score >32).
- PCI may be a viable alternative for patients with low-to-moderate anatomical complexity (SYNTAX score 0-32).
Background:
Several updated meta-analyses comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for left main coronary artery disease (LM CAD) have been published recently. However, the risk of false-positive results could be high in conventional updated meta-analyses due to repetitive testing of accumulating data. Therefore, we compared these treatment approaches via trial sequential analysis (TSA).
Methods:
The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for published randomized controlled trials (RCTs) or subgroups of RCTs comparing PCI and CABG in patients with LM CAD. The primary outcome was major cardiac and cerebrovascular adverse events (MACCE). TSA was used to confirm the conclusions derived from conventional meta-analysis.
Results:
Six RCTs with 4700 patients were included. PCI was associated with a greater risk of MACCE compared with CABG (pooled relative risk [RR] 1.21, 95% confidence interval [CI]: 1.05-1.40, P = .008). In addition, PCI resulted in a significantly higher risk of revascularization than CABG (pooled RR 1.61, 95% CI: 1.33-1.95, P < .0001). TSA provided firm evidence for the reduction of MACCE and revascularization with CABG compared with PCI (cumulative z-curve crossed the monitoring boundary). In the subgroup analysis, CABG was better than PCI in patients with SYNTAX score >32 (pooled RR 1.41, 95% CI: 1.12-1.76, P = .003), which was confirmed by the TSA. There was no difference in patients with a SYNTAX score from 0 to 32.
Conclusions:
In patients with LM CAD, CABG may be better than PCI for reducing MACCE due to a reduced risk of revascularization. CABG remains the first choice for LM CAD patients with high anatomic complexity, while PCI could be an alternative for those with low-to-moderate anatomic complexity.
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