June 05, 2017

Study digs into decadelong controversy of optimal revascularization strategy for left main coronary artery disease

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Authors conclude that the relationship between the complexity of left main coronary artery disease and clinical outcomes varies over time and lay out approaches for individualized strategy of revascularization.

coronary diseaseArora says empowering patients with individualized information, and involving them in shared decision-making, is how one makes the best decisions in cases of significant LMD.Physician-scientists from the University of Alabama at Birmingham have published comparative risks and benefits of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in left main coronary artery disease in European Heart Journal Quality of Care & Clinical Outcomes.

Coronary artery disease occurs when the coronary arteries become narrowed or blocked as a result of atherosclerosis. Atherosclerosis is the build-up of fatty deposits and plaque on the inner walls of the arteries that restricts blood flow to the heart. Without adequate blood flow, the heart is starved of the oxygen and vital nutrients it needs to function properly. The most common symptom of coronary artery disease is angina or chest pain.

PCI, also known as coronary angioplasty, is a nonsurgical procedure that uses a catheter to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by atherosclerosis. With CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses the blocked portion of the coronary artery. This creates a new path for oxygen-rich blood to flow to the heart muscle.

Coronary artery disease occurs when the coronary arteries become narrowed or blocked as a result of atherosclerosis. The most common symptom of coronary artery disease is angina or chest pain.

A team of researchers from UAB identified six randomized controlled trials with 4,700 patients comparing PCI and CABG for left main coronary artery disease (LMD) revascularization. Investigators reported data on major adverse cardiovascular and cerebrovascular events (MACCE), which comprise death, myocardial infarction (MI), stroke and repeat revascularization.

“In light of the recent data and aforementioned deficits in literature, we sought to conduct a meta-analysis comparing CABG and PCI to look at differences in clinical outcomes with LMD revascularization,” said UAB’s Navkaranbir S. Bajaj, first co-author of the study.

Bajaj says, in previously conducted studies, there was lack of assessment of outcomes at different time points — 30 days, one year and the long term — between CABG and PCI.

Researchers have found clinical benefit on long-term MACCE in favor of CABG for revascularization in patients with significant LMD. On the contrary, rates of MACCE at 30 days were lower in the PCI-arm driven by lower rates of stroke in those undergoing PCI. At one year, there was a clinical symmetry where MACCE rates were balanced by higher stroke rates in the CABG arm and higher revascularization rates in the PCI arm. However, at long-term follow-up, overall MACCE rates were lower in the CABG arm. Moreover, MACCE rates were higher in patients with a high SYNTAX score, a grading tool to determine the complexity of coronary artery disease.

“To provide individualized care to our cardiac patients, we need to think above and beyond the traditionally used SYNTAX risk score,” said senior author Pankaj Arora M.D., assistant professor in the UAB Division of Cardiovascular Disease. “Our current analysis gives insight into the needs for a careful discussion between the patient and a multidisciplinary ‘heart-team’ prior to treatment selection.”

He says empowering patients with individualized information, and involving them in shared decision-making, is how one makes the best decisions in cases of significant LMD. Authors concluded that the intricate relationship between the complexity of LMD and clinical outcomes varies over time and lay out different approaches for individualized strategy of revascularization.

Bajaj and UAB’s Nirav Patel, M.D., first co-authors of European Heart Journal Quality of Care and Clinical Outcomes study, designed and conducted the analyses for the study.

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