A 72-year-old female presents with unstable angina. She has a known history of coronary artery disease and had undergone coronary artery bypass grafting two years prior, with a saphenous vein graft anastomosed to the LAD as her LIMA was found to be atretic. Additional medical history is significant for hypertension, hyperlipidemia, and COPD with two exacerbations in the last month. Her ECG revealed sinus rhythm with poor R wave progression across the precordial leads, and non-specific T wave inversions. She underwent diagnostic left heart catheterization which revealed an occluded venous graft, a discrete 80% ostial left main lesion, 60% proximal LAD lesion, and up to 70% stenoses in the circumflex and right coronary artery. Echocardiography revealed preserved LV systolic function. Due to her significant lung disease, she was felt to be a better candidate for unprotected left main PCI rather than re-do CABG.
Based on the PRECOMBAT trial, which of the following statements is true for this patient:
Show Answer
The correct answer is: E. This patient would have been excluded from the PRECOMBAT trial due to previous CABG
Rationale:
Recent guidelines consider PCI to be a potential alternative to CABG for ULMCA stenosis. The 2011 ACC/AHA Guidelines for Percutaneous Coronary Intervention give a Class IIa recommendation for UPLMCA PCI when the patient is not a candidate for CABG in the setting of UA/NSTEMI. Major clinical outcomes are similar when PCI is compared with CABG, and mortality rates are similar at one, two, and five years after follow-up. The risk of needing target vessel revascularization, however, is higher with PCI than with CABG.
The PRECOMBAT trial was a prospective, open-label, randomized trial comparing PCI with sirolimus-eluting stents and CABG for optimal revascularization of patients with ULMCA stenosis. However, the study excluded patients with any PCI within the prior 12 months, patients with STEMI on presentation, patients with LV EF <30% or in cardiogenic shock, and patients who had previously undergone CABG.
This patient would have been excluded from the trial due to prior CABG.
References
Park, SJ et al. "Randomized trial of stents versus bypass surgery for left main coronary artery disease." N Engl J Med 2011; 364:1718-1727
Bates, ER et al. "2011 ACCF/AHA/SCAI Practice Guidelines for percutaneous coronary Intervention." Circulation 2011; 124:e574-e651
Fihn, SD et al. "2012 ACCF/AGA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Stable Ischemic Heart Disease." Circulation 2012; 126; e354-e471
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