Left main lesions in acute coronary syndrome (ACS) represent a major risk and, at present, the best revascularization strategy is a matter of debate. Though many studies and registries have excluded this group of patients, there is data on the pros and cons of both percutaneous coronary intervention (PCI) and cardiac artery bypass graft (CABG).
This analysis looked at 4 randomized studies comparing PCI with drug eluting stents (DES) vs. CABG (SYNTAX, PRECOMBAT, NOBLE and EXCEL) including a total of 1,466 patients (33.4%) with SCA and 2,927 without SCA (NSCA).
Primary end point was all cause mortality at 5 years. Mean age was 65 and most patients were men. There were no significant differences between the groups, except for a higher prevalence of diabetes, prior MI, ejection fraction <50 and higher SYNTAX score, among SCA patients (26.4 vs. 25.2; p < 0.001).
Time from randomization to procedure was shorter in patients undergoing PCI.
At 30 days, there was higher cardiovascular and non-cardiovascular mortality in SCA patients vs. NACS (1.8 vs. 0.5 p<0.001 AND 1.9 vs. 0.5 p<0.001 respectively).
MI rate was higher in ACS patients both at one and five year followup (2.3% vs. 1.0%; HR 2.73, 95% CI ;1.63-4.58; p < 0.001 and 5.7% vs. 3.8%; HR 1.70, 95%CI: 1.25-2.31; p < 0.001, respectively).
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MI rate was higher in ACS patients both at one and five year followup (2.3% vs. 1.0%; HR 2.73, 95% CI ;1.63-4.58; p < 0.001 and 5.7% vs. 3.8%; HR 1.70, 95%CI: 1.25-2.31; p < 0.001, respectively).
Primary end point resulted similar with PCI for both ACS and NACS patients (10.9% vs 11.5% HR, 0.93; 95% CI, 0.68-1.27 and 11.3%vs 9.6% HR, 1.19; 95% CI, 0.95-1.50 respectively). There was a lower rate of stroke in the PCI group, but this group also showed higher need for repeat revascularization or MI vs. CABG patients.
Conclusion
Among patients undergoing left main revascularization with low to intermediate coronary anatomical complexity, patients presenting ACS had a higher rate of early mortality. However, 5-year mortality was similar between PCI and CABG. In the short term, PCI had a relative advantage over CABG in terms of stroke.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Percutaneous Coronary Intervention vs Coronary Artery Bypass Graft Surgery for Left Main Disease in Patients With and Without Acute Coronary Syndromes. A Pooled Analysis of 4 Randomized Clinical Trials
Reference: Prakriti Gaba, et al. JAMA Cardiol. doi:10.1001/jamacardio.2023.1177.
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