The GRACE registry study, presented in the HOT LINE II session yesterday, showed that PCI is now used preferentially in higher risk patients and is associated with frequent repeat revascularisations; surgery is performed preferentially in lower risk patients and associated with better survival, but more frequent strokes. The registry represents one of the largest data sets ever for ULMCD. The objective of this analysis was to describe the practice of ULMCD revascularisation in ACS patients, and follow its evolution over eight years.
The Global Registry of Acute Coronary Events (GRACE) is an observational study based on 43, 018 patients presenting with ACS between 2000 and 2007 to 106 hospitals in 14 countries. From the database, 1799 patients with ACS and unprotected left main stem were identified; of these 514 had undergone PCI alone, 612 CABG alone, and 673 had undergone no revascularisation procedures and only received medical treatment.
Presenting the data, Gilles Montalescot from the Institute of Cardiology in Paris said the GRACE results showed that overall in-hospital mortality for ULMCD was 7.7%, but reached 11% in patients who presented with STEMI or new left bundle branch block, and was as high as 34% for patients with cardiogenic shock or cardiac arrest.
Montalescot said the analysis explored whether there were links between the type of revascularisation and mortality, and found that both PCI and CABG showed an early mortality hazard for revascularisation. "But when the analysis was repeated for the time period from discharge to six months, revascularisation improved survival rate. It’s clear from this study that the two modes of revascularisation are useful and probably complementary.”
The registry revealed that CABG revascularisation was associated with a fivefold increase in stroke compared with the other two groups, a complication also identified in the SYNTAX study.
The registry also revealed that over the past eight years the number of PCI procedures performed has shown a steady increase over CABG. In 2000 the rate of CABG utilisation was 2.5 times higher than the rate of PCI, but by 2007 the PCI rate was 40%, while CABG was 25%.
“This reflects how clinicians are feeling more confident about tackling difficult cases with PCI,” said Montalescot.
The study was reported simultaneously by the European Heart Journal, and in an accompanying editorial Roberto Corti and Stefan Toggweiler from the University Hospital in Zurich, Switzerland, note that the study provides important new data, highlighting the importance of prompt and complete revascularisation in patients presenting with ACS and left main coronary artery disease.