Key result
PCI with everolimus-eluting stents yielded similar 3-year rates of death, stroke, or MI compared to CABG across all LVEF strata (Pinteraction=0.90), despite higher absolute risks in HFrEF.
Why the study?
The study evaluated the impact of left ventricular ejection fraction on 3-year outcomes in patients with left main coronary artery disease undergoing PCI or CABG in the EXCEL trial.
Does PCI with everolimus-eluting stents compared to CABG improve the composite of death, stroke, or myocardial infarction at 3 years in patients with left main coronary artery disease across different LVEF categories?
RCT (n=1,804)
Does PCI with everolimus-eluting stents compared to CABG improve the composite of death, stroke, or myocardial infarction at 3 years in patients with left main coronary artery disease across different LVEF categories?
p-value: p=0.90
In patients with left main coronary artery disease, clinical outcomes at 3 years were similar between PCI and CABG regardless of baseline LVEF, although lower LVEF was associated with higher overall mortality.
Supports similar PCI or CABG outcomes in left main disease across LVEF; extends randomized evidence to HFrEF and HFmrEF strata.
Aim To evaluate the impact of left ventricular ejection fraction (LVEF) on 3-year outcomes in patients with left main coronary artery disease (LMCAD) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in the EXCEL trial. Methods and results The EXCEL trial randomized patients with LMCAD to PCI with everolimus-eluting stents (n = 948) or CABG (n = 957). Among 1804 patients with known baseline LVEF, 74 (4.1%) had LVEF <40% [heart failure with reduced ejection fraction (HFrEF)], 152 (8.4%) LVEF 40–49% [heart failure with mid-range ejection fraction (HFmrEF)] and 1578 (87.5%) LVEF ≥50% (heart failure with preserved ejection fraction). Patients with HFrEF vs. HFmrEF vs. preserved LVEF experienced a longer postoperative hospital stay (9.0 vs. 7.0 vs. 6.0 days, P = 0.02) with greater peri-procedural complications after CABG, while hospital stay after PCI was unaffected by LVEF (1.5 vs. 2.0 vs. 1.0 days, P = 0.20). The composite primary endpoint of death, stroke, or myocardial infarction at 3 years was 29.3% (PCI) vs. 27.6% (CABG) in patients with HFrEF, 16.2% vs. 15.0% in patients with HFmrEF, and 14.5% vs. 14.6% in those with preserved LVEF, respectively (Pinteraction= 0.90). Smoothing spline analysis demonstrated that the 3-year risk of all-cause death increased when LVEF decreased, both in patients undergoing CABG and PCI. Conclusion In the EXCEL trial, the composite rate of death, stroke or myocardial infarction at 3 years was significantly higher in patients with HFrEF compared with HFmrEF or preserved LVEF, driven by an increased rate of all-cause death. No significant differences after PCI vs. CABG were observed among patients with HFrEF, HFmrEF and preserved LVEF. Longer-term follow-up could provide important insights on differences in clinical outcomes that might emerge over time. Clinical Trial Registration: ClinicalTrials.gov Identifier NCT01205776.
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Thuijs et al. (2020) conducted an RCT in left main coronary artery disease (LMCAD) (n=1,804). PCI with everolimus-eluting stents vs. CABG was evaluated on composite of death, stroke, or myocardial infarction at 3 years (p=0.90). PCI with everolimus-eluting stents yielded similar 3-year rates of death, stroke, or MI compared to CABG across all LVEF strata (Pinteraction=0.90), despite higher absolute risks in HFrEF.
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