Clinical outcomes with percutaneous coronary revascularization vs coronary artery bypass grafting surgery in patients with unprotected left main coronary artery disease

A meta-analysis of 6 randomized trials and 4,686 patients

Tullio Palmerini, Patrick Serruys, Arie Pieter Kappetein, Philippe Genereux, Diego Della Riva, Letizia Bacchi Reggiani, Evald Christiansen, Niels R. Holm, Leif Thuesen, Timo Makikallio, Marie Claude Morice, Jung Min Ahn, Seung Jung Park, Holger Thiele, Enno Boudriot, Mario Sabatino, Mattia Romanello, Giuseppe Biondi-Zoccai, Raphael Cavalcante, Joseph F. Sabik & 1 others Gregg W. Stone

Research output: Contribution to journalArticle

24 Citations (Scopus)

Abstract

Some but not all randomized controlled trials (RCT) have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative to coronary artery bypass grafting (CABG) surgery for the treatment of unprotected left main coronary artery disease (ULMCAD). We therefore aimed to compare the risk of all-cause mortality between PCI and CABG in patients with ULMCAD in a pairwise meta-analysis of RCT. Methods Randomized controlled trials comparing PCI vs CABG for the treatment of ULMCAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. Results Six trials including 4,686 randomized patients were identified. After a median follow-up of 39 months, there were no significant differences between PCI vs CABG in the risk of all-cause mortality (hazard ratio [HR] 0.99, 95% CI 0.76-1.30) or cardiac mortality. However, a significant interaction for cardiac mortality (Pinteraction=.03) was apparent between randomization arm and SYNTAX score, such that the relative risk for mortality tended to be lower with PCI compared with CABG among patients in the lower SYNTAX score tertile, similar in the intermediate tertile, and higher in the upper SYNTAX score tertile. Percutaneous coronary intervention compared with CABG was associated with a similar long-term composite risk of death, myocardial infarction, or stroke (HR 1.06, 95% CI 0.82-1.37), with fewer events within 30 days after PCI offset by fewer events after 30 days with CABG (Pinteraction <.0001). Percutaneous coronary intervention was associated with greater rates of unplanned revascularization compared with CABG (HR 1.74, 95% CI 1.47-2.07). Conclusions In patients undergoing revascularization for ULMCAD, PCI was associated with similar rates of mortality compared with CABG at a median follow-up of 39 months, but with an interaction effect suggesting relatively lower mortality with PCI in patients with low SYNTAX score and relatively lower mortality with CABG in patients with high SYNTAX score. Both procedures resulted in similar long-term composite rates of death, myocardial infarction, or stroke, with PCI offering an early safety advantage and CABG demonstrating greater durability.

Original languageEnglish (US)
Pages (from-to)54-63
Number of pages10
JournalAmerican Heart Journal
Volume190
DOIs
StatePublished - Aug 1 2017

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Percutaneous Coronary Intervention
Coronary Artery Bypass
Meta-Analysis
Coronary Artery Disease
Mortality
Randomized Controlled Trials
Stroke
Myocardial Infarction
Drug-Eluting Stents
Random Allocation
MEDLINE
Databases
Safety

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine

Cite this

Palmerini, Tullio ; Serruys, Patrick ; Kappetein, Arie Pieter ; Genereux, Philippe ; Riva, Diego Della ; Reggiani, Letizia Bacchi ; Christiansen, Evald ; Holm, Niels R. ; Thuesen, Leif ; Makikallio, Timo ; Morice, Marie Claude ; Ahn, Jung Min ; Park, Seung Jung ; Thiele, Holger ; Boudriot, Enno ; Sabatino, Mario ; Romanello, Mattia ; Biondi-Zoccai, Giuseppe ; Cavalcante, Raphael ; Sabik, Joseph F. ; Stone, Gregg W. / Clinical outcomes with percutaneous coronary revascularization vs coronary artery bypass grafting surgery in patients with unprotected left main coronary artery disease : A meta-analysis of 6 randomized trials and 4,686 patients. In: American Heart Journal. 2017 ; Vol. 190. pp. 54-63.
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abstract = "Some but not all randomized controlled trials (RCT) have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative to coronary artery bypass grafting (CABG) surgery for the treatment of unprotected left main coronary artery disease (ULMCAD). We therefore aimed to compare the risk of all-cause mortality between PCI and CABG in patients with ULMCAD in a pairwise meta-analysis of RCT. Methods Randomized controlled trials comparing PCI vs CABG for the treatment of ULMCAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. Results Six trials including 4,686 randomized patients were identified. After a median follow-up of 39 months, there were no significant differences between PCI vs CABG in the risk of all-cause mortality (hazard ratio [HR] 0.99, 95{\%} CI 0.76-1.30) or cardiac mortality. However, a significant interaction for cardiac mortality (Pinteraction=.03) was apparent between randomization arm and SYNTAX score, such that the relative risk for mortality tended to be lower with PCI compared with CABG among patients in the lower SYNTAX score tertile, similar in the intermediate tertile, and higher in the upper SYNTAX score tertile. Percutaneous coronary intervention compared with CABG was associated with a similar long-term composite risk of death, myocardial infarction, or stroke (HR 1.06, 95{\%} CI 0.82-1.37), with fewer events within 30 days after PCI offset by fewer events after 30 days with CABG (Pinteraction <.0001). Percutaneous coronary intervention was associated with greater rates of unplanned revascularization compared with CABG (HR 1.74, 95{\%} CI 1.47-2.07). Conclusions In patients undergoing revascularization for ULMCAD, PCI was associated with similar rates of mortality compared with CABG at a median follow-up of 39 months, but with an interaction effect suggesting relatively lower mortality with PCI in patients with low SYNTAX score and relatively lower mortality with CABG in patients with high SYNTAX score. Both procedures resulted in similar long-term composite rates of death, myocardial infarction, or stroke, with PCI offering an early safety advantage and CABG demonstrating greater durability.",
author = "Tullio Palmerini and Patrick Serruys and Kappetein, {Arie Pieter} and Philippe Genereux and Riva, {Diego Della} and Reggiani, {Letizia Bacchi} and Evald Christiansen and Holm, {Niels R.} and Leif Thuesen and Timo Makikallio and Morice, {Marie Claude} and Ahn, {Jung Min} and Park, {Seung Jung} and Holger Thiele and Enno Boudriot and Mario Sabatino and Mattia Romanello and Giuseppe Biondi-Zoccai and Raphael Cavalcante and Sabik, {Joseph F.} and Stone, {Gregg W.}",
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Palmerini, T, Serruys, P, Kappetein, AP, Genereux, P, Riva, DD, Reggiani, LB, Christiansen, E, Holm, NR, Thuesen, L, Makikallio, T, Morice, MC, Ahn, JM, Park, SJ, Thiele, H, Boudriot, E, Sabatino, M, Romanello, M, Biondi-Zoccai, G, Cavalcante, R, Sabik, JF & Stone, GW 2017, 'Clinical outcomes with percutaneous coronary revascularization vs coronary artery bypass grafting surgery in patients with unprotected left main coronary artery disease: A meta-analysis of 6 randomized trials and 4,686 patients', American Heart Journal, vol. 190, pp. 54-63. https://doi.org/10.1016/j.ahj.2017.05.005

Clinical outcomes with percutaneous coronary revascularization vs coronary artery bypass grafting surgery in patients with unprotected left main coronary artery disease : A meta-analysis of 6 randomized trials and 4,686 patients. / Palmerini, Tullio; Serruys, Patrick; Kappetein, Arie Pieter; Genereux, Philippe; Riva, Diego Della; Reggiani, Letizia Bacchi; Christiansen, Evald; Holm, Niels R.; Thuesen, Leif; Makikallio, Timo; Morice, Marie Claude; Ahn, Jung Min; Park, Seung Jung; Thiele, Holger; Boudriot, Enno; Sabatino, Mario; Romanello, Mattia; Biondi-Zoccai, Giuseppe; Cavalcante, Raphael; Sabik, Joseph F.; Stone, Gregg W.

In: American Heart Journal, Vol. 190, 01.08.2017, p. 54-63.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Clinical outcomes with percutaneous coronary revascularization vs coronary artery bypass grafting surgery in patients with unprotected left main coronary artery disease

T2 - A meta-analysis of 6 randomized trials and 4,686 patients

AU - Palmerini, Tullio

AU - Serruys, Patrick

AU - Kappetein, Arie Pieter

AU - Genereux, Philippe

AU - Riva, Diego Della

AU - Reggiani, Letizia Bacchi

AU - Christiansen, Evald

AU - Holm, Niels R.

AU - Thuesen, Leif

AU - Makikallio, Timo

AU - Morice, Marie Claude

AU - Ahn, Jung Min

AU - Park, Seung Jung

AU - Thiele, Holger

AU - Boudriot, Enno

AU - Sabatino, Mario

AU - Romanello, Mattia

AU - Biondi-Zoccai, Giuseppe

AU - Cavalcante, Raphael

AU - Sabik, Joseph F.

AU - Stone, Gregg W.

PY - 2017/8/1

Y1 - 2017/8/1

N2 - Some but not all randomized controlled trials (RCT) have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative to coronary artery bypass grafting (CABG) surgery for the treatment of unprotected left main coronary artery disease (ULMCAD). We therefore aimed to compare the risk of all-cause mortality between PCI and CABG in patients with ULMCAD in a pairwise meta-analysis of RCT. Methods Randomized controlled trials comparing PCI vs CABG for the treatment of ULMCAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. Results Six trials including 4,686 randomized patients were identified. After a median follow-up of 39 months, there were no significant differences between PCI vs CABG in the risk of all-cause mortality (hazard ratio [HR] 0.99, 95% CI 0.76-1.30) or cardiac mortality. However, a significant interaction for cardiac mortality (Pinteraction=.03) was apparent between randomization arm and SYNTAX score, such that the relative risk for mortality tended to be lower with PCI compared with CABG among patients in the lower SYNTAX score tertile, similar in the intermediate tertile, and higher in the upper SYNTAX score tertile. Percutaneous coronary intervention compared with CABG was associated with a similar long-term composite risk of death, myocardial infarction, or stroke (HR 1.06, 95% CI 0.82-1.37), with fewer events within 30 days after PCI offset by fewer events after 30 days with CABG (Pinteraction <.0001). Percutaneous coronary intervention was associated with greater rates of unplanned revascularization compared with CABG (HR 1.74, 95% CI 1.47-2.07). Conclusions In patients undergoing revascularization for ULMCAD, PCI was associated with similar rates of mortality compared with CABG at a median follow-up of 39 months, but with an interaction effect suggesting relatively lower mortality with PCI in patients with low SYNTAX score and relatively lower mortality with CABG in patients with high SYNTAX score. Both procedures resulted in similar long-term composite rates of death, myocardial infarction, or stroke, with PCI offering an early safety advantage and CABG demonstrating greater durability.

AB - Some but not all randomized controlled trials (RCT) have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative to coronary artery bypass grafting (CABG) surgery for the treatment of unprotected left main coronary artery disease (ULMCAD). We therefore aimed to compare the risk of all-cause mortality between PCI and CABG in patients with ULMCAD in a pairwise meta-analysis of RCT. Methods Randomized controlled trials comparing PCI vs CABG for the treatment of ULMCAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. Results Six trials including 4,686 randomized patients were identified. After a median follow-up of 39 months, there were no significant differences between PCI vs CABG in the risk of all-cause mortality (hazard ratio [HR] 0.99, 95% CI 0.76-1.30) or cardiac mortality. However, a significant interaction for cardiac mortality (Pinteraction=.03) was apparent between randomization arm and SYNTAX score, such that the relative risk for mortality tended to be lower with PCI compared with CABG among patients in the lower SYNTAX score tertile, similar in the intermediate tertile, and higher in the upper SYNTAX score tertile. Percutaneous coronary intervention compared with CABG was associated with a similar long-term composite risk of death, myocardial infarction, or stroke (HR 1.06, 95% CI 0.82-1.37), with fewer events within 30 days after PCI offset by fewer events after 30 days with CABG (Pinteraction <.0001). Percutaneous coronary intervention was associated with greater rates of unplanned revascularization compared with CABG (HR 1.74, 95% CI 1.47-2.07). Conclusions In patients undergoing revascularization for ULMCAD, PCI was associated with similar rates of mortality compared with CABG at a median follow-up of 39 months, but with an interaction effect suggesting relatively lower mortality with PCI in patients with low SYNTAX score and relatively lower mortality with CABG in patients with high SYNTAX score. Both procedures resulted in similar long-term composite rates of death, myocardial infarction, or stroke, with PCI offering an early safety advantage and CABG demonstrating greater durability.

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