PCI is becoming the preferred strategy for some ACS patients who have unprotected left main coronary disease (ULMCD), according to Gilles Montalescot, who presented the latest results of the GRACE registry at the ESC. The results were published simultaneously in European Heart Journal.
Using data from 43,000 patients who have been enrolled in GRACE between 2000 and 2008, Montalescot reported on 1,799 who had ULMCD. Within this group, 514 had PCI, 612 had CABG, and 673 did not undergo revascularization. Over the course of the study Montalescot said there had been a steady shift toward PCI and away from CABG. Patients with STEMI, cardiac arrest, or cardiogenic shock were more likely to get PCI. Nearly half of PCI patients underwent revascularization on the day of admission. By contrast, only 5% of CABG patients underwent surgery on the first day.
In-hospital mortality was 7.7%. Mortality was highest in the PCI group, as expected due to their higher risk scores, while CABG patients had the lowest mortality. Patients who had revascularization were more likely to die early, but following discharge they had improved survival.
“The results show that CABG surgery and PCI are not used in similar types of patients and provide complementary treatment options in ACS,” said Montaescot, in an ESC press release. When feasible, PCI is the preferred strategy for the most urgent and sickest cases, he said.
Click here to read the paper published simultaneously in European Heart Journal.
Click here to read the EHJ commentary by Roberto Corti and Stefan Toggweiler.
Click here to view Christian Hamm’s discussion slides for the presentation.
Here is the ESC press release:
Revascularisation strategies for unprotected left main coronary disease: results from a GRACE registry study – PCI and CABG appear to provide complementary treatment options in ULMCD patients
PRESS RELEASE – ESC CONGRESS 2009 – Hot Line II
Barcelona, Spain, 31 August 2009: Launched in 1999, the Global Registry of Acute Coronary Events (GRACE) is the world’s largest international database tracking outcomes of patients presenting with acute coronary syndromes (ACS),including myocardial infarction or unstable angina. GRACE data are derived from 247 hospitals in North America, South America, Europe, Asia, Australia and New Zealand, and from more than 100,000 patients with ACS. Data from 43,018 ACS patients in the Registry were analysed to determine the optimal revascularisation strategy for unprotected left main coronary disease, which has so far been little studied.
Results of the analysis showed that unprotected left main coronary disease (ULMCD) in ACS is associated with high in-hospital mortality, especially in patients presenting with STEMI (ST segment elevation myocardial infarction) and/or hemodynamic or arrhythmic instability. PCI (percutaneaous coronary intervention) is now the most common revascularisation strategy in this population, and is preferred in higher-risk patients. CABG (coronary artery bypass grafting) is often delayed and is associated with the best 6-month survival. The two approaches therefore appear complementary in this high-risk group.
Findings
Of the 43,018 patients in the analysis, 1799 had significant ULMCD and underwent PCI alone (n=514), CABG alone (n=612), or no revascularisation (n=673). Mortality was 7.7% in hospital and 14% at six months.
Over the eight-year study period, the GRACE risk score remained constant, 20 points higher in PCI than in CABG, but there was a steady shift to more PCI than CABG revascularisation over time.* Patients undergoing PCI presented more frequently with acute myocardial infarction, after cardiac arrest, or in cardiogenic shock; 48% of PCI patients underwent revascularisation on the day of admission vs. 5.1% in the CABG group. After adjustment, revascularisation was associated with an early hazard of hospital death compared with no revascularisation, significant for PCI (HR 2.60, 95% CI 1.62-4.18) but not for CABG (HR 1.26, 95% CI 0.72-2.22).
From discharge to six months, both PCI (HR 0.45, 95% CI 0.23-0.85) and CABG (HR 0.11, 95% CI 0.04-0.28) were significantly associated with improved survival in comparison with an initial strategy of no revascularisation. CABG revascularisation was associated with a five-fold increase in stroke compared with the other two groups.
Says investigator Professor Gilles Montalescot from the Hôpital Pitié-Salpétrière in Paris: “The results show that CABG surgery and PCI are not used in similar types of patients and provide complementary treatment options in ACS.”
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