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PCI comparable to CABG in left main CAD treatment
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Although CABG has been the standard therapy for patients with left main coronary artery stenosis, new data suggest that PCI with drug-eluting stents may be a valid alternative treatment.
Daniele Giacoppo, MD, from the German Heart Center Munich and the Technical University of Munich, and colleagues performed a meta-analysis recently published in JAMA Cardiology comparing long-term safety of PCI with DES vs. CABG in patients with left main coronary artery stenosis.
CABG vs. PCI
The analysis included randomized clinical trials published between December 2001 and February 1, 2017.
“For decades, the standard approach to left main coronary artery revascularization has been through CABG given its ability to safely and effectively achieve complete revascularization,” Cardiology Today’s Intervention Editorial Board Member Ajay J. Kirtane, MD, SM, cardiologist, chief academic officer at the Center for Interventional Vascular Therapy at Columbia University Medical Center, director of NewYork-Presbyterian and Columbia Catheterization Laboratories, Columbia University Medical Center and NewYork-Presbyterian Hospital, and Robert O. Bonow, MD, MS, Max and Lilly Goldberg distinguished professor of cardiology and professor of medicine at Northwestern University Feinberg School of Medicine, wrote in an accompanying editorial comment. “More recently, revascularization through PCI has been proposed as an alternative to CABG for traditionally surgical anatomy.”
Giacoppo and colleagues pooled data from four randomized clinical trials covering 4,394 patients (mean age, 65.4 years; 76.7% men).
The researchers also performed sensitivity analyses according to DES generation and CAD complexity.
The primary endpoint of the meta-analysis was a composite of all-cause mortality, MI, or stroke at long-term follow-up.
Secondary endpoints included repeat revascularization and a composite of all-cause mortality, MI, stroke or repeat revascularization at long-term follow-up.
There were comparable rates of all-cause death, MI, stroke risk between PCI and CABG by fixed-effect (HR = 1.06; 95% CI, 0.9-1.24) as well as random-effects (HR = 1.06; 95% CI, 0.85-1.32) analysis.
The researchers found that sensitivity analyses according to low to intermediate SYNTAX score (random-effects HR = 1.02; 95% CI, 0.74-1.41) and DES generation (HR for first generation = 0.9; 95% CI, 0.68-1.2; HR for second generation = 1.19; 95% CI, 0.82-1.73) were consistent.
There were no significant variations over time between the techniques, with a 5-year incidence of all-cause mortality, MI, or stroke of 18.3% in patients treated with PCI and 16.9% in patients treated with CABG, according to the Kaplan-Meier curve reconstruction. However, PCI was correlated with increased risk for repeat revascularization (HR = 1.7; 95% CI, 1.42-2.05).
Giacoppo and colleagues found no significant differences between other individual secondary end points between groups.
Patient characteristics key
In a related viewpoint, Marc Ruel, MD, PhD, from the University of Ottawa Heart Institute, and colleagues wrote the most important factor in the CABG vs. PCI debate may be patient preference.
“For many patients who have left main disease with concomitant complex multivessel disease (as assessed by the Syntax score), the preferred revascularization modality may remain CABG, but for patients with high comorbidity burden or high stroke risk, PCI would be preferred,” they wrote. – by Dave Quaile
References:
Giacoppo D, et al. JAMA Cardiol. 2017;doi:10.1001/jamacardio.2017.2895.
Kirtane A, Bonow RO. JAMA Cardiol. 2017;doi:10.1001/jamacardio.2017.3154.
Ruel M, et al. JAMA Cardiol. 2017;doi:10.1001/jamacardio.2017.2946.
Disclosures: Bonow reports no relevant financial disclosures. Giacoppo reports he receives grant support from the European Association of Percutaneous Coronary Intervention. Kirtane reports he receives institutional research grants from Abbott Vascular, Abiomed, Boston Scientific, Cardiovascular Systems Inc., CathWorks, Medtronic and Siemens. Ruel reports he has financial ties with Abbott, Bristol-Myers Squibb, Cryolife, Edwards Lifesciences, Medtronic and Sanofi Aventis. Please see the study and editorials for all other authors’ relevant financial disclosures.