There are many current randomized trials comparing percutaneous coronary intervention (PCI) with myocardial revascularization surgery (MRS) for the treatment of left main coronary artery disease (LMCAD).
In the European Society of Cardiology guidelines, PCI is classified as Ia (LMCAD with low-complexity coronary disease) or IIa indication (intermediate complexity), whereas, according to the American Heart Association it is classified as IIa evidence (when PCI revascularization has results equivalent to MRS). Despite evidence and recommendations, the treatment of LMCAD remains a controversial matter. Moreover, there is little information of real-world observational studies comparing these two interventions (PCI and MRS).
This retrospective study aims at comparing long-term results of PCI and MRS in patients with LMCAD.
The primary endpoint (PEP) was all-cause mortality. Secondary endpoints (SEP) were major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, readmission for acute myocardial infarction (AMI), stroke, and repeat revascularization. There was also a safety endpoint, which was mortality at 30 days, defined as in-hospital or 30-day death after a revascularization procedure.
Between 2008 and 2020, 2526 patients were included in the PCI arm and 21,287 in the MRS arm. Propensity score matching (PSM) was conducted to homogenize both arms. A total of 1128 patients were analyzed in each arm. Before conducting the PSM, the PCI arm had a more elderly population that included more women; however, this population had a lower coronary disease rate.
Regarding short-term results, there were no significant differences in early death (P = 0.0750), in-hospital death (P = 0.913), and stroke (P = 0.201). Nevertheless, the PCI arm had higher AMI rates (P = 0.007).
Regarding results at 7 years, survival was 46 % for the PCI arm and 64 % for the MRS arm (P < 0.0001). The cumulative incidence of AMI was greater in the PCI arm compared with the MRS arm (P < 0.0001), and the need for repeat revascularization was more frequent in the PCI arm (P < 0.0001). Stroke incidence was lower in the PCI arm compared with the MRS arm (P < 0.001).
Conclusion
MRS is associated with better long-term results compared with PCI in patients with LMCAD. These results indicate that MRS should be the preferred revascularization strategy for patients who meet surgery requirements.
Dr. Andrés Rodríguez.
Member of the Editorial Board of SOLACI.org.
Original Title: Real-World Examination of Revascularization Strategies for Left Main Coronary Disease in Ontario, Canada.
Reference: Derrick Y. Tam, MD et al J Am Coll Cardiol Intv 2023.
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