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PCI or CABG for Left Main Coronary Artery Disease
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- This observational study of all-comers with left main coronary artery (LMCA) disease reports that CABG was associated with lower mortality and fewer cardiovascular or cerebrovascular events compared to PCI after adjustment for confounders.
- This study may further help choose between CABG and PCI for LMCA disease, especially for real-world patients who are not represented in randomized clinical trials.
- These data also provide further support to a Class I recommendation for CABG over PCI in LMCA disease in the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization, which states that in patients with stable ischemic heart disease with significant LMCA disease, CABG is recommended to improve survival.
Study Questions:
What are the outcomes after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in unprotected left main coronary artery (LMCA) disease?
Methods:
The investigators used an observational nationwide all-comers prospective register study to analyze outcomes after CABG or PCI in unprotected LMCA disease. All patients undergoing coronary angiography in Sweden are registered in the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry. Between January 1, 2005 and December 31, 2015, 11,137 patients with LMCA disease underwent CABG (n = 9,364) or PCI (n = 1,773). Patients with previous CABG, ST-elevation myocardial infarction (MI), or cardiac shock were excluded. Death, MI, stroke, and new revascularization during follow-up until December 31, 2015 were identified using national registries. Cox regression with inverse probability weighting (IPW) and an instrumental variable (IV), administrative region, were used.
Results:
Patients undergoing PCI were older and had higher prevalence of comorbidity but lower prevalence of three-vessel disease. PCI patients had higher mortality than CABG patients after adjustments for known confounders with IPW analysis (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.5-2.7) and known/unknown confounders with IV analysis (HR, 1.5; 95% CI, 1.1-2.0). PCI was associated with higher incidence of major adverse cardiovascular and cerebrovascular events (MACCE; death, MI, stroke, or new revascularization) than CABG, with IV analysis (HR, 2.8; 95% CI, 1.8-4.5). There was a quantitative interaction for diabetic status regarding mortality (p = 0.014) translating into 3.6-year (95% CI, 3.3-4.0) longer median survival time favoring CABG in patients with diabetes.
Conclusions:
The authors report that CABG in patients with LMCA disease was associated with lower mortality and fewer MACCE compared to PCI after multivariable adjustment for known and unknown confounders.
Perspective:
This observational study of all-comers with LMCA disease reports that CABG was associated with lower mortality and fewer cardiovascular or cerebrovascular events compared to PCI after adjustment for confounders. This study may further help choose between CABG and PCI for LMCA disease, especially for real-world patients who are not represented in randomized clinical trials. These data also provide further support to a Class I recommendation for CABG over PCI in LMCA disease in the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) Guideline for Coronary Artery Revascularization, which states that in patients with stable ischemic heart disease with significant LMCA disease, CABG is recommended to improve survival. Of note, in choosing between CABG and PCI, it is important to use the Heart Team to determine the optimal revascularization strategy, with specific considerations of anatomic complexity, medication compliance, and individual patient preference.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Cardiac Surgical Procedures, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Patient Care Team, Percutaneous Coronary Intervention, Stroke
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