Both coronary artery bypass grafting (CABG) and stenting procedures show similar rates of death and the composite end point of death, Q Wave MI and stroke, reports a five year follow-up of patients with unprotected left main stem coronary (LMCA) disease (1). The Korean study, published in the Journal of the American College of Cardiology (JACC), however, found that repeat target revascularization was significantly higher among the patients who underwent percutaneous interventions, be it with bare metal (BMS) or drug-eluting stents (DES).
Patients with unprotected LMCA disease are widely considered to represent a high risk group that absolutely requires revascularization. Although CABG is still being recommended as the standard treatment for unprotected LMCA disease, percutaneous interventions are increasing in frequency due to improvements in techniques and drug therapies.
Duk-Woo Park and colleagues, from the University of Ulsan College of Medicine (Seoul, Korea), undertook a long term follow up of 2,240 patients enrolled in the MAIN –COMPARE study, a Korean registry designed to evaluate real-world outcomes of coronary stenting and CABG for unprotected LMCA at 12 cardiac centres in Korea between January 2000 and June 2006. Outcomes at a median of three years were reported in 2008 by the same authors in the New England Journal of Medicine (2).
Commenting on the latest analysis, European Society of Cardiology (ESC) spokesman William Wijns, said: “The study in JACC gives the same message as the 2008 NEJM paper, namely that PCI in selected unprotected LMCA is achievable, and not associated with worse outcomes than CABG. The only thing this paper adds to the original analysis is longer follow-up.”
One aspect of the paper, he added, that was a little surprising was that the need for repeat intervention was not found to be lower for DES than BMS. “Every other trial has shown that the one thing DES does really well is reduce restenosis,” said Wijns, adding the explanation for the lack of difference in the current study may be due to the “asymmetry” of follow-up. BMS were used for all subjects until 2003, after which the investigators switched to using DES. Follow-up at 5 years was available in 67% of patients with BMS versus only 29% of patients treated with DES.
“This study should be added to the increasing hypothesis-generating signals emerging from various trials and registries that there may be a place for PCI in the treatment of selected patients with unprotected LMCA. The limitation of the study remains that it is a registry, possibly confounded by selection bias for either therapy. Ultimately only a prospective multi-centre randomised trial will provide the definitive answer,” he said, adding that currently the NOBLE study has started enrolment, and the PRECOMBAT and EXCEL studies are at the final planning stage.
At ESC Congress 2010, (Stockholm, Sweden, 28 August – 1 September), a joint Task Force of the ESC and the European Association for Cardiothoracic Surgery (EACTS) will present the first Joint Guidelines on Myocardial Revascularisation. “This paper provides further information that the Task Force will use to come up with recommendations,” said Wijns, from the Aalst Cardiovascular Centre in Belgium.
1. Park DW, Seung KB, Kim YH et al. Long-Term Safety and Efficacy of Stenting Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery Disease: 5-Year Results From the MAIN –COMPARE Registry. JACC 2010; 20: 00:00 doi:10.1016/j.jacc.2010.04.004 2. Seung KB, Park DW, Kin YH, et al. Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med 2008; 358:1781-92.
* Unprotected left main stem coronary (LMCA) disease refers to a blockage in the left coronary artery before it divides into the left anterior descending branch and the left circumflex artery. It is these vessels that are responsible for supplying the largest part of the left ventricular muscle with blood and oxygen, thereby enabling the heart to pump blood via the aorta to all parts of the body. When the left main coronary artery is blocked, patients face an extreme medical emergency.
“Unprotected” refers to the fact that the area supplied by these vessels is not supported by a previously implanted bypass conduit.
* The European Society of Cardiology (ESC) represents more than 62,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.
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