JACC: PCI may be equivalent to CABG for patients with LMCA disease

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In patients with left main coronary artery (LMCA) disease, PCI was associated with non-significantly different one-year rates of major adverse cardiac and cerebrovascular events (MACCE), death and MI, a lower risk of stroke, and a higher risk of target vessel revascularization (TVR) compared with CABG. The meta-analysis was published Sept. 27 in the Journal of the American College of Cardiology.

Previous meta-analyses of PCI vs. CABG in LMCA disease mainly included non-prospective, observational studies. Several new randomized controlled trials (RCTs) have recently been reported. 

Davide Capodanno, MD, from the cardiology department at Ferrarotto Hospital in Catania, Italy, and colleagues identified 1,611 patients from four randomized clinical trials for the present meta-analysis.

The primary endpoint used was one-year incidence of MACCE, defined as death, MI, TVR or stroke. The clinical endpoint definitions were similar among the trials.

PCI was associated with a non-significantly higher one-year rate of MACCE compared with CABG (14.5 vs. 11.8 percent), driven by increased TVR (11.4 vs. 5.4 percent), according to the authors.

Conversely, stroke occurred less frequently with PCI (0.1 vs. 1.7 percent), and there were no significant differences in death (3 vs. 4.1 percent) or MI (2.8 vs. 2.9 percent). 

“From the available RCT data, no significant differences were present between PCI and CABG in patients with LMCA disease for the occurrence of one-year MACCE and the component endpoints of death or MI,” Capodanno and colleagues concluded. “However, PCI was associated with higher rates of TVR but with fewer CVAs [cerebrovascular accidents] compared with CABG. Based on the present study, revision of the guidelines regarding left main PCI is warranted, raising the level of evidence of current recommendations from B to A.”

Of note, the researchers suggested that the ongoing EXCEL trial is only including patients with mild to moderate anatomic complexity (SYNTAX score less than or equal to 32), for which the advantages of CABG over PCI may be less evident. The SYNTAX score roughly correlates with the extent of coronary atherosclerosis and this meta-analysis supports revascularization by CABG in patients with three-vessel disease, Capodanno et al wrote.