Real-World Treatment Selection Factors and 7-Year Clinical Outcomes between Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in Left Main Disease

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Left main coronary artery disease (n=230). Intervention: Percutaneous coronary intervention (PCI) with drug-eluting stents vs. Coronary artery bypass graft (CABG) surgery. Primary outcome: Major adverse cardiovascular events (MACE), defined as a composite of cardiac death, spontaneous myocardial infarction (MI), stroke, and target vessel revascularization (TVR) for 7 years (HRadj 0.97, 95% CI 0.48–1.94, p=0.92).

Q: What does this research mean for the field?

Percutaneous coronary intervention results in a similar 7-year rate of major adverse cardiovascular events compared to coronary artery bypass grafting in patients with left main coronary disease. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Albert Youngwoo Jang; Minsu Kim; Joonpyo Lee; Jeongduk Seo; Yong Hoon Shin; Pyung Chun Oh; Soon Yong Suh; Kyounghoon Lee; Woong Chol Kang; Taehoon Ahn; Seung Hwan Han

doi:10.3390/jcm11030503

January 19, 2022Journal of Clinical MedicineOpen Access

Real-World Treatment Selection Factors and 7-Year Clinical Outcomes between Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in Left Main Disease

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Key result

PCI shows similar 7-year major cardiovascular events rates compared to CABG in left main disease.

HRadj 0.97
95% CI 0.48–1.94
P=0.92
n=230

Figures

Why the study?

Decision-making factors and long-term clinical outcomes between PCI and CABG in left main disease are not well defined in the real world.

Does percutaneous coronary intervention (PCI) with drug-eluting stents result in comparable 7-year major adverse cardiovascular events compared to coronary artery bypass graft (CABG) surgery in real-world patients with left main coronary artery disease?

Key Points

To identify clinical and angiographic factors determining the choice between PCI and CABG in real-world left main coronary artery disease and compare their 7-year clinical outcomes.
Evaluated consecutive patients (n = 230) with left main disease treated with either PCI (n = 118) or CABG (n = 112) with a median follow-up of 89 months.
Assessed the primary endpoint of 7-year major adverse cardiovascular events (MACE), defined as a composite of cardiac death, spontaneous myocardial infarction, stroke, and target vessel revascularization (TVR).
Intermediate EuroSCORE II and high SYNTAX scores independently predicted selection for CABG, whereas isolated left main disease was associated with receiving PCI.
The PCI group had a similar rate of MACE (HRadj 0.97, 95% CI [0.48–1.94], p = 0.92) and a trend toward lower hard MACE (HRadj 0.49, 95% CI [0.22–1.07], p = 0.07) compared with CABG.

Study Design

Type

Cohort (n=230)

Multicenter

No

Structured PICO

Does percutaneous coronary intervention (PCI) with drug-eluting stents result in comparable 7-year major adverse cardiovascular events compared to coronary artery bypass graft (CABG) surgery in real-world patients with left main coronary artery disease?

P

Population

230 adults with left main coronary artery disease (mean age 64.1 years, 28% female) undergoing either PCI (n=118) or CABG (n=112), excluding those with concurrent valve surgery or cardiogenic shock, followed for a median of 89 months.

E

Exposure

Percutaneous coronary intervention (PCI) using drug-eluting stents (DES) (mean stent diameter 3.4 mm and length 20.9 mm in the main vessel), assigned by attending doctors after discussion with patients and family members.

C

Comparator

Coronary artery bypass graft (CABG) surgery (mean 2.3 grafts used per surgery, internal mammary artery used 94.6% of the time, off-pump surgery in 42.9%).

O

Outcome

Major adverse cardiovascular events (MACE), defined as a composite of cardiac death, spontaneous myocardial infarction (MI), stroke, and target vessel revascularization (TVR) for 7 years (median follow-up 89 months, IQR 32.0–127.5), adjudicated by consensus of two or more cardiologists.composite

Main Result

Hazard Ratio: 0.97 (95% CI 0.48–1.94)

p-value: p=0.92

In real-world practice, clinician and patient selection of PCI versus CABG based on clinical risk (EuroSCORE II) and anatomical complexity (SYNTAX score, isolated LM disease) yields comparable 7-year MACE rates and a trend toward fewer hard clinical endpoints with PCI.

Limitations

Single-center retrospective observational design, which may be strongly influenced by local practices and limits generalizability
Propensity score matching analysis with an acceptable caliper width resulted in a much smaller sample size (66 patients per group)
Unmeasured confounding factors such as patient financial status or fear of surgery may have influenced treatment selection
Intrinsic limitation of a single-center retrospective observational study, meaning results might be strongly influenced by local practices and not generalizable
Unmeasurable factors such as patient's financial status or fear of surgery may have played a role in determining PCI or CABG and confounded the analysis

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Implication

Comparable 7-year MACE with PCI or CABG in selected left main patients; supports risk-based decisions but leaves open randomized confirmation.

Abstract

Background: The decision-making factors and long-term clinical outcomes between PCI and CABG in left main (LM) disease are still not well defined in the real world. Methods: We evaluated consecutive patients (n = 230) with LM disease either treated by PCI (n = 118) or CABG (n = 112). The primary endpoint was major adverse cardiovascular events (MACE), defined as a composite of cardiac death, spontaneous myocardial infarction (MI), stroke, and target vessel revascularization (TVR) for 7 years. Results: In the multivariate-adjusted analysis, the presence of intermediate EuroSCORE II and high SYNTAX scores predisposed to CABG. Isolated LM disease was associated with receiving PCI. The PCI group had a similar rate of MACE (HRadj 0.97, 95% CI [0.48–1.94], p = 0.92) and a lower tendency of hard MACE (HRadj 0.49, 95% CI [0.22–1.07], p = 0.07) compared to the CABG group, mainly due to the balance between a higher rate of TVR (HRadj 9.71, p = 0.02) and a lower rate of stroke (HRadj 0.22, p = 0.09) with the PCI group than in the CABG group. Conclusions: The decision making of treatment strategy was made based on clinical and angiographic factors. The selected patients who received PCI showed similar MACE and trend of a lower rate of composite hard endpoints despite multivariate adjustment.

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Cite This Study

Jang et al. (2022) conducted a cohort in Left main coronary artery disease (n=230). Percutaneous coronary intervention (PCI) with drug-eluting stents vs. Coronary artery bypass graft (CABG) surgery was evaluated on Major adverse cardiovascular events (MACE), defined as a composite of cardiac death, spontaneous myocardial infarction (MI), stroke, and target vessel revascularization (TVR) for 7 years (HRadj 0.97, 95% CI 0.48–1.94, p=0.92). Percutaneous coronary intervention resulted in a similar 7-year rate of major adverse cardiovascular events compared to CABG in left main disease.

synapsesocial.com/papers/6a78f568fc98817f16020a46 https://doi.org/10.3390/jcm11030503

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Real-World Treatment Selection Factors and 7-Year Clinical Outcomes between Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in Left Main Disease

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Real-World Treatment Selection Factors and 7-Year Clinical Outcomes between Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in Left Main Disease

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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