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PCI a safe option for left main CAD and ACS: study

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – In patients with left main coronary artery disease (CAD) and acute coronary syndrome (ACS), percutaneous coronary intervention (PCI) is a safe option that carries a similar risk of death and re-infarction as coronary artery bypass grafting (CABG), new research shows.

However, PCI carries a significantly higher risk of major adverse cardiac events, driven by more frequent repeat revascularizations, the researchers found.

“Similarly to non-ACS presentations, PCI patients experience a higher risk of re-intervention, perhaps inflated by a more liberal use of follow up angiography compared to CABG,” Dr. Davide Capodanno, who worked on the study, commented in an e-mail to Reuters Health.

The best revascularization strategy for patients with left main CAD presenting with ACS remains uncertain, the study team, from the Cardiovascular Department, Ferrarotto Hospital, Catania, Italy, notes in the May 5 online issue of American Journal of Cardiology.

They determined 1-year clinical outcomes in a group of contemporary patients with left main CAD and ACS who were treated with PCI and drug-eluting stents (n = 222) or CABG (n = 364).

At 1 year, major adverse cardiac events were significantly higher in the PCI group than the CABG group (14.4% vs 5.3%; P < 0.001). This was driven by a higher rate of target lesion revascularization with PCI (8.1% vs 1.7%; P = 0.001). This difference persisted after statistical adjustment for major adverse cardiac events (adjusted hazard ratio 2.7) and target lesion revascularization (adjusted hazard ratio 8.0).

Follow-up angiography was significantly associated with higher odds of major adverse cardiac events and target lesion revascularization at 1-year follow-up (P < 0.001 for both). There were no statistically significant differences in rates of death (6.3% for PCI vs 3.6% for CABG) and myocardial infarction (1.8% vs 0.6%).

The lack of a significant correlation between clinical presentation (unstable angina/non-ST-segment elevation MI or ST-segment elevation MI) and treatment strategy is noteworthy, the clinicians say. “It seems from our data that the clinical scenario in which a left main stenosis is detected does not significantly interact with the type of revascularization offered to the patient,” Dr. Capodanno told Reuters Health.

“Decision making might not necessarily rely on whether the patients present with an ACS or not,” he commented. “This is consistent with the notion that score algorithms — such as the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score – have been proven to work well in stable angina patients as well as in those with an ACS,” he noted.

“Therefore, guidelines recommendations for using scores to aid decision making in left main disease may also theoretically apply to ACS patients. However, the impact of other clinical variables could be not negligible. Therefore, careful patient selection on a case-by-case basis is necessary,” Dr. Capodanno concludes.

Lack of random assignment to treatment is the most important limitation of the current analysis, he and his colleagues note in their report, adding that “only randomization can provide an unbiased estimation of effects of a treatment.”

In addition, because the “presumptive benefit of CABG is likely to increase over time, longer follow-up would add meaningfully to the present report.”

Am J Cardiol 2011.