Major Bleeding and Mortality After Revascularization of Left Main Disease

Area of Science:

• Cardiovascular Medicine
• Interventional Cardiology
• Clinical Trials

Background:

• Major bleeding (MB) incidence and prognostic impact after left main coronary artery disease (LMCAD) revascularization remain unclear.
• Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are primary treatments for LMCAD.

Purpose of the Study:

• To investigate the rates and outcomes of major bleeding (MB) following LMCAD revascularization with PCI versus CABG.
• To assess the association between MB and subsequent mortality.

Main Methods:

• Analysis of 1,905 patients from the EXCEL trial with unprotected LMCAD, randomized to PCI (n=948) or CABG (n=957).
• MB defined by TIMI major/minor, BARC types 3-5, or transfusion-requiring bleeding; follow-up for 5 years.
• Time-adjusted Cox regression models used to assess MB's association with mortality.

Main Results:

• At 5 years, 11.4% of patients experienced MB. CABG had higher 5-year MB rates (14.8%) compared to PCI (7.9%).
• In-hospital MB was lower with PCI (3.8%) versus CABG (13.5%), but post-discharge MB was higher with PCI (4.5%) versus CABG (2.0%).
• MB events within 5 years significantly increased the risk of all-cause mortality (HR: 2.71), driven by both cardiovascular and non-cardiovascular causes.

Conclusions:

• Coronary artery bypass grafting (CABG) is associated with higher overall and in-hospital major bleeding (MB) rates compared to percutaneous coronary intervention (PCI) for left main coronary artery disease.
• Post-discharge MB is more frequent after PCI than CABG.
• Major bleeding following either LMCAD revascularization strategy independently predicts increased cardiovascular and non-cardiovascular mortality within 5 years.