Left main coronary disease: five-year outcomes after PCI vs CABG

  • Stone GW & al.
  • N Engl J Med
  • 28 Sep 2019

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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Takeaway

  • In patients with left main coronary artery disease of low or intermediate anatomical complexity, no significant difference was observed between percutaneous coronary intervention (PCI) with everolimus-eluting stents and coronary artery bypass grafting (CABG) regarding the composite outcome of death, stroke or myocardial infarction (MI) at 5 years.

Why this matters

  • At present, there is no clarity regarding the long-term outcomes after PCI or CABG in patients with left main coronary artery disease.

Study design

  • EXCEL trial of 1905 patients with left main coronary artery disease of low or intermediate anatomical complexity comparing PCI with everolimus-eluting stents with CABG during 2010-2015.
  • Patients were randomly assigned to PCI (n=948) and CABG (n=957) groups.
  • Primary outcome: composite of death, stroke or MI at 3 years.
  • Funding: Abbott Vascular.

Key results

  • The primary outcome occurred in 22.0% of patients in the PCI vs 19.2% in the CABG group (difference, 2.8 percentage points; 95% CI, −0.9 to 6.5; P=.13).

  • At 5-years, PCI vs CABG group demonstrated no significant difference in the incidence of:
    • definite cardiovascular death (5.0% vs 4.5%; OR, 1.13; 95% CI, 0.73-1.74);
    • myocardial infarction (10.6% vs 9.1%; OR, 1.14; 95% CI, 0.84-1.55); and
    • stroke (2.9% vs 3.7%; OR, 0.78; 95% CI, 0.46-1.31).
  • PCI vs CABG showed higher rates of all-cause mortality (13.0% vs 9.9%; OR, 1.38; 95% CI, 1.03-1.85).
  • Incidences of all cerebrovascular events (3.3% vs 5.2%; OR, 0.61; 95% CI, 0.38-0.99) and definite stent thrombosis (0.3% vs 1.2%; HR, 0.27; 95% Cl, 0.08-0.97) were less frequent after PCI than that after CABG.
  • Ischaemia-driven revascularisation was performed more frequently after PCI than CABG (16.9% vs 10.0%; OR, 1.84; 95% CI, 1.39-2.44).

Limitations

  • Risk of bias.