Deferred Versus Performed Revascularization for Left Main Coronary Disease With Hemodynamic Significance
Takayuki Warisawa1,2,3, Christopher M Cook4,5, Yousif Ahmad6
1Division of Cardiology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan (T.W., S.D., Y.J.A.).
Insights
Revascularization significantly improves long-term outcomes for stable left main coronary artery disease (LMD) patients with ischemia. Deferred treatment led to more major adverse cardiac events compared to prompt revascularization.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Left main coronary artery disease (LMD) is often excluded from major trials, leaving outcomes data scarce.
- Understanding the long-term results of treating significant LMD with ischemia is crucial.
Purpose of the Study:
- To compare long-term clinical outcomes of revascularization versus deferral in patients with stable, physiologically significant LMD.
Main Methods:
- An international multicenter registry analyzed stable LMD patients with ischemia (iFR ≤0.89).
- Patients were divided into revascularization (n=151) and deferral (n=74) groups.
- Propensity score matching adjusted for baseline characteristics; primary endpoint was MACE (death, MI, ischemia-driven TVR).
Main Results:
- At 2.8 years, the primary endpoint occurred in 14.9% of revascularized vs. 28.4% of deferred patients (HR 0.42, P=0.023).
- Cardiac death/MI was lower in the revascularized group (0.0% vs. 8.1%, P=0.004).
- Ischemia-driven LMTVR was significantly lower post-revascularization (5.4% vs. 17.6%, HR 0.20, P=0.012).
Conclusions:
- Revascularization significantly improves long-term clinical outcomes in stable LMD patients with significant ischemia.
- Deferred treatment for significant LMD carries a higher risk of adverse cardiac events.
Background:
The majority of randomized controlled trials of revascularization decision-making excludes left main coronary artery disease (LMD). Therefore, contemporary clinical outcomes of patients with stable coronary artery disease and LMD with proven ischemia remain poorly understood. The aim of this study was to assess the long-term clinical outcomes of physiologically significant LMD according to the treatment strategies of revascularization versus revascularization deferral.
Methods:
In this international multicenter registry of stable LMD interrogated with the instantaneous wave-free ratio, patients with physiologically significant ischemia (instantaneous wave-free ratio ≤0.89) were analyzed according to the coronary revascularization (n=151) versus revascularization deferral (n=74). Propensity score matching was performed to adjust for baseline clinical characteristics. The primary end point was a composite of death, nonfatal myocardial infarction, and ischemia-driven target lesion revascularization of left main stem. The secondary end points were as follows: cardiac death or spontaneous LMD-related myocardial infarction; and ischemia-driven target lesion revascularization of left main stem.
Results:
At a median follow-up period of 2.8 years, the primary end point occurred in 11 patients (14.9%) in the revascularized group and 21 patients (28.4%) in the deferred group (hazard ratio, 0.42 [95% CI, 0.20-0.89]; P=0.023). For the secondary end points, cardiac death or LMD-related myocardial infarction occurred significantly less frequently in the revascularized group (0.0% versus 8.1%; P=0.004). The rate of ischemia-driven target lesion revascularization of left main stem was also significantly lower in the revascularized group (5.4% versus 17.6%; hazard ratio, 0.20 [95% CI, 0.056-0.70]; P=0.012).
Conclusions:
In patients who underwent revascularization for stable coronary artery disease and physiologically significant LMD determined by instantaneous wave-free ratio, the long-term clinical outcomes were significantly improved as compared with those in whom revascularization was deferred.
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