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Stroke risk lower with PCI than CABG for left main coronary artery disease

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Results of a meta-analysis of randomized trials indicate that percutaneous coronary intervention for left main coronary artery (LMCA) disease is associated with less risk of subsequent stroke than is coronary artery bypass graft surgery, while the likelihood of target vessel revascularization within a year is higher.

Those findings are reported in the September 27 issue of the Journal of the American College of Cardiology by Dr. Davide Capodanno, with the Ferrarotto Hospital in Catania, Italy, and colleagues. “Based on the present study,” they conclude, “revision of the guidelines regarding left main PCI is warranted, raising the level of evidence of current recommendations from B to A.”

The authors explain that current guidelines carry a B level of evidence because of a lack of randomized data. The current analysis is based on four new randomized trials involving 1611 patients.

The team found that the primary endpoint of major adverse cardiac or cerebrovascular events (MACCE) within 1 year was higher with PCI (14.5%) than with CABG (11.8%), but the difference was not statistically significant.

The difference in 1-year MACCE was driven largely by the higher rate of target vessel revascularization with PCI (11.4%) than CABG (5.4%), the investigators point out. On the other hand, stroke was less frequent following PCI than CABG (0.1% vs 1.7%), while there was no significant difference in deaths and MIs.

“Many clinicians believe that TVR (target vessel revascularization) is of less clinical importance than death, MI, or stroke, arguably being more comparable to numerous other adverse outcomes such as bleeding, renal failure, or atrial fibrillation,” Dr. Capodanno and colleagues comment.

In fact, the composite of death, MI and stroke (CVA) in their analysis was 5.3% versus 6.8% with PCI compared to CABG (p=0.26), the report indicates.

“The present study may thus be informative to guide future trials comparing PCI and CABG for LMCA disease with a more relevant endpoint, such as the composite of death/MI/CVA,” the authors conclude.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery in Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Clinical Data
J Am Coll Cardiol 2011;58:1426–432.