TCT 2017: PCI, CABG yield similar long-term results for left main CAD patients

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Heart patients with left main coronary artery disease (LMCAD) could benefit from more immediate results when receiving percutaneous coronary intervention (PCI) over coronary artery bypass graft surgery (CABG), according to research presented at this year’s Transcatheter Cardiovascular Therapeutics (TCT) symposium, though both procedures yield similar quality of life improvements after three years.

These findings stem from 2016’s international EXCEL trial, which randomized LMCAD patients undergoing revascularization to either PCI using everolimus-eluting stents or CABG, and found that rates of death, stroke and myocardial infarction were similar in both study groups after three years of observation. However, patients randomized to PCI saw increased instances of repeat revascularization, and CABG patients were more likely to experience a myocardial infarction within 30 days post-surgery. The EXCEL findings were presented at last year’s TCT conference and published in the New England Journal of Medicine.

Ninety-three percent—1,788 of 1,905—patients who participated in the EXCEL trial took part in the quality of life (QoL) sub-study, according to information presented at TCT. Using the Seattle Angina Questionnaire, SF-12, Rose Dyspnea Scale, Patient Health Questionnaire-8 and EQ-5D, Suzanne J. Baron, MD, and colleagues assessed patients’ quality of life at baseline and then at one, 12 and 36 months after undergoing either PCI or CABG. To be included in the study, participants needed to have either low- or intermediate-complexity LMCAD.

The PCI group saw quicker responses, with both disease-specific and generic health status measures improving significantly after just one month post-procedure. Those perks, including freedom from angina and reduced clinical depression, sustained themselves throughout the study period. Patients who underwent CABG saw similarly positive long-term results but experienced fewer improvements, and even declines, in their health at one month. Researchers concluded via longitudinal random-effect growth curve models that both operations were nearly equal in effect—a finding inconsistent with previous studies that have found CABG to be preferential to PCI in LMCAD patients.

“For any treatment, it’s important to not only consider clinical outcomes such as recurrent heart attacks or stroke, but also to consider the effect of the treatment on a patient’s quality of life,” Baron said in a release from Abbott Vascular, whose XIENCE coronary stent was used in the study's PCI trial. “These data demonstrate that PCI is a reasonable treatment option for patients with LMCAD that allows them to potentially avoid surgery and to rapidly obtain a better quality of life after revascularization.”

Daniel B. Mark, MD, MPH, wrote in an editorial accompanying the EXCEL-QoL study that patients face a difficult decision when it comes to what kind of operation they choose to undergo—one that often involves balancing quality of life with major adverse outcomes like heart attack or stroke.

“Compounding the treatment choice problem, patients often arrive at the therapeutic encounter with pre-existing preferences based on unrealistic beliefs about the benefits revascularization will offer, beliefs that are not easily corrected, even with structured educational efforts to do so,” he said. “At present, to understand what therapy would work best for them, patients must immerse themselves in the technical jungle of evidence-based medicine. No wonder that many give up the struggle and choose whatever the doctor recommends.”

Baron’s findings will be published today in the Journal of the American College of Cardiology following a presentation at TCT in Denver.