Outcomes of patients with and without baseline lipid-lowering therapy undergoing revascularization for left main
Shmuel Chen1, Björn Redfors1,2, Yangbo Liu1
1Clinical Trials Center, Cardiovascular Research Foundation.
Insights
Baseline lipid-lowering therapy (LLT) did not alter major adverse event rates after left main coronary artery disease (CAD) revascularization. However, patients on LLT had more revascularizations after percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG).
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Limited data exists on the impact of baseline lipid-lowering therapy (LLT) in patients with left main coronary artery disease (LMCAD) undergoing revascularization.
- Understanding treatment effects based on LLT status is crucial for optimizing patient outcomes.
Purpose of the Study:
- To compare outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for LMCAD in patients with and without baseline LLT.
- To assess the influence of baseline LLT on major adverse events and need for revascularization after revascularization procedures.
Main Methods:
- Analysis of data from the EXCEL trial, which randomized 1905 patients with LMCAD to PCI or CABG.
- Patients were stratified based on the presence of LLT at baseline.
- Outcomes were analyzed using multivariable Cox proportional hazards regression, with a primary endpoint of death, stroke, or myocardial infarction at 3 years.
Main Results:
- No significant difference in the 3-year primary endpoint rates between PCI and CABG groups, regardless of baseline LLT status (Pinteraction=0.62).
- Patients with baseline LLT showed a higher rate of ischemia-driven revascularization after PCI compared to CABG (13.7% vs. 5.3%, P<0.0001).
- In contrast, patients without baseline LLT did not show a significant difference in revascularization rates between PCI and CABG (Pinteraction=0.0003).
Conclusions:
- Major adverse event rates at 3 years were similar after PCI versus CABG for LMCAD, irrespective of baseline LLT.
- Baseline LLT was associated with a higher likelihood of subsequent revascularization after PCI compared to CABG.
- Treatment decisions for LMCAD should consider the potential impact of baseline LLT on long-term outcomes and need for repeat procedures.
Objectives:
There is a paucity of data on the effect of baseline lipid-lowering therapy (LLT) in patients undergoing revascularization for left main (LM) coronary artery disease (CAD). We compared outcomes for patients with LMCAD randomized to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) according to the presence of baseline LLT in the EXCEL trial.
Patients And Methods:
The EXCEL trial randomized 1905 patients with LMCAD and SYNTAX scores up to 32 to PCI with everolimus-eluting stents versus CABG. Patients were categorized according to whether they were medically treated with LLT at baseline, and their outcomes were examined using multivariable Cox proportional hazards regression. The primary endpoint was a composite of death, stroke, or myocardial infarction at 3 years.
Results:
Among 1901 patients with known baseline LLT status, 1331 (70.0%) were medically treated with LLT at baseline. There were no significant differences between the PCI and CABG groups in the 3-year rates of the primary endpoint in patients with versus without baseline LLT (Pinteraction=0.62). Among patients with baseline LLT, the 3-year rate of ischemia-driven revascularization was higher after PCI compared with CABG (13.7 vs. 5.3%; adjusted hazard ratio=2.97; 95% confidence interval: 1.95-4.55; P<0.0001), in contrast to patients without baseline LLT (9.8 vs. 12.1%; adjusted hazard ratio=0.79; 95% confidence interval: 0.47-1.33; P=0.39) (Pinteraction=0.0003).
Conclusion:
In the EXCEL trial, 3-year major adverse event rates after PCI versus CABG for LMCAD were similar and consistent in patients with and without LLT at baseline; however, revascularization during follow-up was more common after PCI compared with CABG in patients with baseline LLT, but not in those without baseline LLT.
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