NOBLE trial-is it time to revise the guidelines?

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Surgery

Background:

• Unprotected left main coronary artery (LMCA) stenosis requires revascularization.
• Current guidelines recommend percutaneous coronary angioplasty (PCI) for select patients.
• The Nordic-Baltic-British left main revascularization trial (NOBLE) investigated revascularization strategies.

Purpose of the Study:

• To compare the efficacy and safety of PCI versus coronary artery bypass grafting (CABG) in patients with unprotected LMCA stenosis.
• To evaluate the primary composite endpoint of all-cause mortality, stroke, myocardial infarction, and repeat revascularization at 5 years.

Main Methods:

• Prospective, randomized, multicentre, non-inferiority trial.
• Enrolled patients with unprotected LMCA stenosis.
• Compared PCI with CABG.

Main Results:

• Coronary artery bypass grafting (CABG) demonstrated superior 5-year MACCE rates (28% vs. 19%) compared to percutaneous coronary angioplasty (PCI).
• PCI was associated with significantly higher rates of non-procedural myocardial infarction and repeat revascularization.
• All-cause mortality and stroke rates were similar between the two groups.

Conclusions:

• The NOBLE trial findings challenge current European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines recommending PCI for unprotected LMCA stenosis with SYNTAX score < 23.
• CABG appears to be a superior revascularization strategy for unprotected LMCA stenosis.
• Further research may be warranted to refine treatment guidelines.