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ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 138-143

Short-term outcomes of left main coronary artery disease treatment: A comparative study of optimal medical therapy, coronary artery bypass grafting, and percutaneous coronary intervention


1 Deparment of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Cardiology, Apollo Hospitals, Secundrabad, Telangana, India

Date of Submission09-Jun-2020
Date of Decision21-Jun-2020
Date of Acceptance07-Jul-2020
Date of Web Publication26-Nov-2020

Correspondence Address:
Dr. Monika Bhandari
Department of Cardiology, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_23_20

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  Abstract 


Background: Several studies have compared treatment strategies in patients with left main coronary artery (LMCA) disease. However, short-term outcomes have scarcely been reported.
Materials and Methods: In this prospective, single-center, descriptive study, conducted between January 1, 2017, and January 1, 2018, patients with LMCA disease were treated through medical follow-up (MFU), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG).
Results: A total of 149 patients participated in the study. Of the 149 patients, 27 (18.1%), 69 (46.3%), and 53 (35.6%) patients were treated with CABG, MFU, and PCI, respectively. The SYNTAX score was 31.0 ± 5.8, 29.9 ± 7.0, and 21.0 ± 6.8 in the CABG, MFU, and PCI groups (P<0.001), respectively. At the 6-month follow-up, 19 (76.0%) and 38 (76.0%) patients presented with New York Heart Association (NYHA) Class I dyspnea in the CABG and PCI groups, respectively, as compared to 29 (59.2%) patients in the MFU group (P = 0.139). Similarly, 22 (88.0%) and 43 (86.0%) patients presented with NYHA Class I angina in the CABG and PCI groups, respectively, as compared to 27 (55.1%) patients in the MFU group (P = 0.033). Death occurred in 1 (3.7%), 10 (17.2%), and 2 (3.8%) patients in the CABG, MFU, and PCI groups (P = 0.033), respectively. Diabetics accounted for 9/13 (69.2%) of the patients who died (P = 0.012).
Conclusion: Optimal medical therapy did not provide any 6-month survival benefits in patients with LMCA disease. However, CABG and PCI present as suitable treatment options for this subset of patients. The majority of the patients who presented with dyspnea and NYHA Class I belonged to the PCI and CABG groups.

Keywords: Coronary artery bypass grafting, left main coronary artery disease, medical follow-up, percutaneous coronary intervention, SYNTAX score


How to cite this article:
Vishwakarma P, Sharma R, Pradhan A, Bhandari M, Sethi R, Sharma A, Chandra S, Chaudhary G, Dwivedi S K, Narain V S. Short-term outcomes of left main coronary artery disease treatment: A comparative study of optimal medical therapy, coronary artery bypass grafting, and percutaneous coronary intervention. Heart India 2020;8:138-43

How to cite this URL:
Vishwakarma P, Sharma R, Pradhan A, Bhandari M, Sethi R, Sharma A, Chandra S, Chaudhary G, Dwivedi S K, Narain V S. Short-term outcomes of left main coronary artery disease treatment: A comparative study of optimal medical therapy, coronary artery bypass grafting, and percutaneous coronary intervention. Heart India [serial online] 2020 [cited 2021 Jan 23];8:138-43. Available from: https://www.heartindia.net/text.asp?2020/8/3/138/301593




  Introduction Top


Coronary artery bypass grafting (CABG) persists as the standard revascularization strategy in patients with left main coronary artery (LMCA) disease.[1],[2] Although previous guidelines recommend percutaneous coronary intervention (PCI) for patients with uncomplicated lesions,[3] the adoption of PCI for complex patient subsets with high-risk anatomical features has been an extensively debated topic. Several trials conducted this past decade have evidenced favorable outcomes with PCI. Such results are attributable to the latest generation coronary stents and improved dual antiplatelet regimens.[4] In view of the outcomes documented by a few milestone trials [5] in more complex patient subsets with challenging coronary anatomy, recent guidelines have accepted PCI as a feasible revascularization technique in selected patients. However, the decision should be a multifactorial decision taken by the local heart team.[6]

Several randomized trials and observational registries have been earlier conducted to determine long-term outcomes of patients with LMCA disease who had undergone different management strategies.[1],[2] However, the current literature reporting short-term outcomes in this population subset is scarce. To fill this gap in the current literature, the present study was conducted to: (i) determine if the current era optimal medical treated with beta-blockers, antiplatelets, and statins improves 6-month survival rates of patients with LMCA disease, (ii) analyze the symptomatic status of patients with LMCA disease who had undergone different treatment strategies at presentation and after 6 months, and (iii) compare the outcomes of patients with LMCA disease.


  Materials and Methods Top


Study design and patient population

A prospective, descriptive, single-center study was conducted on patients with LMCA disease at our tertiary care center between January 1, 2017, and January 1, 2018. Patients with previous CABG, significantly associated valvular heart disease, chronic renal failure on renal replacement therapy, and active malignancy were excluded from the study. All patients provided written informed consent for the procedure, data collection and analysis for research purpose. The study was approved by the institutional ethical committee.

Intervention

PCI was performed through radial or femoral route. A single- or double-stent strategy was implemented. Contrast used was Visipaque or Omnipaque. Fractional flow reserve (FFR) and bifurcation stenting were performed if required.

Data acquisition and patient follow-up

Demographic data such as age, gender, clinical risk factors, history of cardiovascular or any other medical ailments were extracted from patient hospital records. Details of clinical presentations such as dyspnea, angina, and left ventricular ejection fraction were recorded. Lesion details such as diseased vessel, number of diseased vessels, lesion site, severity of calcification, length of diseased segment, SYNTAX score, and bifurcation lesions were collected from angiography and angioplasty reports. Procedural details such as number of grafts, type of graft, intra-aortic balloon pump (if used) for CABG, access route, stenting strategy, number of stents implanted, stent length, bifurcation stenting, and FFR (if used) for PCI were also documented. Patients were followed up at 6 months. Adverse events such as death and hospitalization were documented.

Statistical analysis

Categorical variables are expressed as counts and percentages and descriptive variables as mean ± standard deviation. Categorical variables were compared with Chi-square test. ANOVA test was used to measure variance. P < 0.05 was considered statistically significant. All statistical analysis was done using the Statistical Package for the Social Sciences (SPSS; Chicago, IL, USA) program, version 15.


  Results Top


A total of 149 patients participated in the study. Follow-up data were available for 27/27 (100%), 58/69 (84.1%), and 52/53 (98.1%) patients undergoing CABG, medical follow-up (MFU), and PCI (P = 0.004). Thus, a total of 12 (8.1%) patients were lost to follow-up. MFU group was a heterogeneous group comprising patients who refused to undergo any intervention (55 [79.6%]), patients where significant LMCA disease was discovered during PCI for non-LMCA culprit vessel (7 [10.1%]), and patients who were advised medical therapy due to nonrevascularizable nature of their disease or noncritical LMCA disease (7 [10.1%]).

Baseline characteristics for the overall study population

The study comprised 149 patients. The age of the study patients ranged from 28 to 82 years, with an average of 59.4 ± 10.5 years. Of the 149 patients, 125 (83.9%) patients were male indicating their predominance. Cardiovascular risk factors such as smoking/tobacco use, diabetes mellitus, and hypertension were observed in 71 (47.7%), 56 (37.6%), and 51 (34.2%) patients, respectively. Six (4.0%), 9 (6.0%), and 17 (11.4%) patients had a history of coronary artery disease (CAD), PCI, and acute coronary syndrome, respectively. The majority of the patients, i.e., 92 (61.7%), presented with dyspnea New York Heart Association (NHYA) Class II. In addition, three-quarters, i.e., 112 (75.2%) patients, presented with angina NHYA Class II. The demographic characteristics, clinical risk factors, and clinical presentation of the studied patients are outlined in [Table 1].
Table 1: Baseline characteristics for the overall study population (n=149)

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Lesion and procedural characteristics for the overall study population

Right coronary dominance was observed in 131 (87.9%) patients. CAD or chronic stable angina, non-ST-elevation myocardial infarction (NSTEMI), and STEMI were the indications in 55 (36.9%), 39 (26.2%), and 32 (21.5%) patients, respectively. Of the 149 patients, 10 (6.7%) had isolated treatment for LMCA disease, 27 (18.1%) had one additional lesion treated, 49 (32.9%) had two additional lesions treated, and 63 (42.3%) had three additional lesions treated. Distal lesions were present in 120 (80.5%) patients. Lesions were tubular and diffuse in 75 (50.3%) and 68 (45.6%) patients, respectively. Calcification was observed in 32 (21.5%) patients. Of the 149 patients, 27 (18.1%), 69 (46.3%), and 53 (35.6%) underwent treatment with CABG, MFU, and PCI, respectively. Everolimus and sirolimus drug-eluting stents were implanted in 28 (52.8%) and 22 (41.5%) of the 53 patients who underwent PCI. The lesion and procedural characteristics for the overall study population are given in [Table 2].
Table 2: Lesion and procedural characteristics for the overall study population (n=149)

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Association of parameters according to their groups

The mean ages were 57.8 ± 9.1 years in the CABG group, 63.5 ± 9.1 years in the MFU group, and 55.0 ± 11.0 years in the PCI group (P < 0.001). There were 36 (52.2%) smokers/tobacco users in the MFU group as compared to 10 (37.0%) and 25 (47.2%) smokers/tobacco users in the CABG and PCI groups, respectively. Hypertensives contributed 9 (33.3%), 27 (39.1%), and 19 (35.8%) patients in the CABG, MFU, and PCI groups, respectively. The SYNTAX score was much lower in the PCI group (21.0 ± 6.8) as compared to the CABG group (31.0 ± 5.8) and MFU group (29.9 ± 7.0). The association of parameters with respect to their groups is detailed in [Table 3].
Table 3: Association of parameters according to their groups

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Six-month outcomes and complications for the overall study population

Inhospital death occurred in 3 (2.0%) patients. Stroke, contrast-induced nephropathy, and congestive cardiac failure occurred in 2 (1.3%), 4 (2.7%), and 3 (2.0%) patients, respectively. The 6-month outcomes are detailed in [Table 4].
Table 4: Six-month outcomes and complications for the overall study population (n=149)

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Six-month symptomatic status of patients according to their groups

Death occurred in 1 (3.7%), 10 (17.2%), and 2 (3.8%) patients in the CABG, MFU, and PCI groups (P = 0.033), respectively. In the CABG and PCI groups, 19 (76.0%) and 38 (76.0%) patients presented with NYHA Class I dyspnea, respectively, as compared to 29 (59.2%) patients in the MFU group (P = 0.139). In the CABG and PCI groups, 22 (88.0%) and 43 (86.0%) patients presented with NYHA Class I angina as compared to 27 (55.1%) patients in the MFU group (P = 0.033). The six-month symptomatic status of patients according to different treatment strategies is described in [Table 5].
Table 5: Six-month symptomatic status of patients according to their groups

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Association of final angiographic description of lesions according to smoking/tobacco use and diabetes

Of the 71 smokers/tobacco users, 4 (5.6%) had isolated treatment for LMCA disease, 12 (16.9%) had one additional lesion treated, 23 (32.4%) had two additional lesions treated, and 32 (45.1%) had three additional lesions treated. Similarly, of the 56 diabetics, 1 (1.8%) had isolated treatment for LMCA disease, 12 (21.4%) had one additional lesion treated, 17 (30.4%) had two additional lesions treated, and 26 (46.4%) had three additional lesions treated. Diabetic patients (9/13) accounted for 69.2% of the patients who died (P = 0.012). The final angiographic description of lesions according to smoking/tobacco use and diabetes is outlined in [Table 6].
Table 6: Association of final angiographic description of lesions according to smoking/tobacco use

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  Discussion Top


Patients with LMCA stenosis are more vulnerable to adverse cardiovascular events and are, therefore, associated with higher mortality.[7] The present study aimed to compare different treatment strategies in patients with LMCA disease. An objective of the study was to determine if modern-day medical therapy conferred any survival benefits in patients with LMCA disease. The 6-month outcomes revealed death in 10 (17.2%), 1 (3.7%), and 2 (3.8%) patients treated with MFU, CABG, and PCI, respectively. Similar mortality rates for PCI and CABG suggest both treatment strategies as favorable options. However, MFU did not show any survival benefits.

Our findings of noninferior outcomes are in line with the outcomes of the milestone SYNTAX,[4] EXCEL,[5] PRECOMBAT,[8] and LE MANS [9] trials and several other registries [10],[11],[12] that reported comparable outcomes with CABG and PCI. However, it is noteworthy that the findings of these studies are attributable to small sample sizes prompting wide inferiority margins, thus confounding study findings.[1] This underlines the need for well-powered, large, randomized trials. A few studies have concluded inferiority with PCI.[13],[14]

Diabetics contributed 37.6% of our study population as compared to 14.9%, 25.0%, 29.0%, and 32.0% diabetics in the NOBLE,[1] SYNTAX,[2] EXCEL,[5] and PRECOMBAT [8] trials. Hence, the large proportion of diabetics may explain the relatively high mortality rate observed in the present study, as diabetics accounted for 9/13 (69.2%) patients who died (P = 0.012).

The milestone SYNTAX trial [2] reported a significant trend revealing the correlation between SYNTAX score and revascularization strategy. The primary endpoint of MACCE in the CABG group was similar in patients with low, intermediate, and high SYNTAX scores. However, in the PCI group, a steep increase in MACCE rate was observed in patients with high SYNTAX scores. This insight led to the current revascularization guidelines recommending revascularization with CABG or PCI in patients with low SYNTAX and intermediate SYNTAX scores. However, PCI is not advised for patients with high SYNTAX scores.[15] The low SYNTAX scores in the PCI group (21.0 ± 6.8) as compared to the CABG (31.0 ± 5.8) and MFU (29.9 ± 7.0) groups in our study should be highlighted.

The present study additionally analyzed the symptomatic status of patients at presentation and 6 months after treatment for LMCA disease. We found that the majority of the patients who underwent PCI and CABG presented with dyspnea on exertion Class I at the 6-month follow-up (19 patients: 76.0 and 38 patients: 76.0%, respectively) as compared to MFU patients (29 patients: 59.2.0%). These findings are in line with those reported in the NOBLE trial [1] in which maximum NHYA Class I and II scores were observed in the PCI group as compared to the CABG group. A similar trend was observed for angina presentation. A larger proportion of CABG patients than PCI presented with Class I angina on exertion (AOE) at the 6-month follow-up (22 patients: 88.0% and 43 patients: 86.0%, respectively) as compared to MFU patients (27 patients: 55.2%). The NOBLE trial [1] also observed more Class I AOE patients at follow-up in CABG patients.

Study limitations

The study was limited by small sample size, limited study follow-up, and the 12 (8.1%) patients who were lost to follow-up.


  Conclusion Top


Patients with LMCA disease had higher mortality rates with optimal medical therapy as compared to patients who underwent revascularization with CABG or PCI. There was no difference in the 6-month outcomes of CABG and PCI. This is likely due to the low SYNTAX score in the PCI group as compared to the CABG group. Hence, LMCA disease requires active intervention with PCI in patients with low SYNTAX score and CABG in high SYNTAX score. This is in accordance with the current guidelines.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical approval

The study was approved by institutional ethical committee.



 
  References Top

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Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009;360:961-72.  Back to cited text no. 2
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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