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Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery Stenosis: A Systematic Review and Meta-analysis.
JAMA Cardiol. 2017 10 01; 2(10):1079-1088.JC

Abstract

Importance

In patients with left main coronary artery (LMCA) stenosis, coronary artery bypass grafting (CABG) has been the standard therapy for several decades. However, some studies suggest that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative.

Objective

To compare the long-term safety of PCI with drug-eluting stent vs CABG in patients with LMCA stenosis.

Data Sources

PubMed, Scopus, EMBASE, Web of Knowledge, and ScienceDirect databases were searched from December 18, 2001, to February 1, 2017. Inclusion criteria were randomized clinical trial, patients with LMCA stenosis, PCI vs CABG, exclusive use of drug-eluting stents, and clinical follow-up of 3 or more years.

Data Extraction and Synthesis

Trial-level hazard ratios (HRs) and 95% CIs were pooled by fixed-effect and random-effects models with inverse variance weighting. Time-to-event individual patient data for the primary end point were reconstructed. Sensitivity analyses according to drug-eluting stent generation and coronary artery disease complexity were performed.

Main Outcomes and Measures

The primary end point was a composite of all-cause death, myocardial infarction, or stroke at long-term follow-up. Secondary end points included repeat revascularization and a composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at long-term follow-up.

Results

A total of 4 randomized clinical trials were pooled; 4394 patients were included in the analysis. Of these, 3371 (76.7%) were men; pooled mean age was 65.4 years. According to Grading of Recommendations, Assessment, Development and Evaluation, evidence quality with respect to the primary composite end point was high. Percutaneous coronary intervention and CABG were associated with a comparable risk of all-cause death, myocardial infarction, or stroke both by fixed-effect (HR, 1.06; 95% CI, 0.90-1.24; P = .48) and random-effects (HR, 1.06; 95% CI, 0.85-1.32; P = .60) analysis. Sensitivity analyses according to low to intermediate Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score (random-effects: HR, 1.02; 95% CI, 0.74-1.41; P = .89) and drug-eluting stent generation (first generation: HR, 0.90; 95% CI, 0.68-1.20; P = .49; second generation: HR, 1.19; 95% CI, 0.82-1.73; P = .36) were consistent. Kaplan-Meier curve reconstruction did not show significant variations over time between the techniques, with a 5-year incidence of all-cause death, myocardial infarction, or stroke of 18.3% (319 events) in patients treated with PCI and 16.9% (292 events) in patients treated with CABG. However, repeat revascularization after PCI was increased (HR, 1.70; 95% CI, 1.42-2.05; P < .001). Other individual secondary end points did not differ significantly between groups. Finally, pooled estimates of trials with LMCA stenosis tended overall to differ significantly from those of trials with multivessel coronary artery disease without left main LMCA stenosis.

Conclusions and Relevance

Percutaneous coronary intervention and CABG show comparable safety in patients with LMCA stenosis and low to intermediate-complexity coronary artery disease. However, repeat revascularization is more common after PCI.

Authors+Show Affiliations

Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.Deutsches Herzzentrum München, Technische Universität München, Munich, Germany. German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany.Deutsches Herzzentrum München, Technische Universität München, Munich, Germany. German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany.Deutsches Herzzentrum München, Technische Universität München, Munich, Germany. German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany.Deutsches Herzzentrum München, Technische Universität München, Munich, Germany. German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany.

Pub Type(s)

Comparative Study
Journal Article
Meta-Analysis
Systematic Review

Language

eng

PubMed ID

28903139

Citation

Giacoppo, Daniele, et al. "Percutaneous Coronary Intervention Vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery Stenosis: a Systematic Review and Meta-analysis." JAMA Cardiology, vol. 2, no. 10, 2017, pp. 1079-1088.
Giacoppo D, Colleran R, Cassese S, et al. Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery Stenosis: A Systematic Review and Meta-analysis. JAMA Cardiol. 2017;2(10):1079-1088.
Giacoppo, D., Colleran, R., Cassese, S., Frangieh, A. H., Wiebe, J., Joner, M., Schunkert, H., Kastrati, A., & Byrne, R. A. (2017). Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery Stenosis: A Systematic Review and Meta-analysis. JAMA Cardiology, 2(10), 1079-1088. https://doi.org/10.1001/jamacardio.2017.2895
Giacoppo D, et al. Percutaneous Coronary Intervention Vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery Stenosis: a Systematic Review and Meta-analysis. JAMA Cardiol. 2017 10 1;2(10):1079-1088. PubMed PMID: 28903139.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery Stenosis: A Systematic Review and Meta-analysis. AU - Giacoppo,Daniele, AU - Colleran,Roisin, AU - Cassese,Salvatore, AU - Frangieh,Antonio H, AU - Wiebe,Jens, AU - Joner,Michael, AU - Schunkert,Heribert, AU - Kastrati,Adnan, AU - Byrne,Robert A, PY - 2017/9/14/pubmed PY - 2019/6/4/medline PY - 2017/9/14/entrez SP - 1079 EP - 1088 JF - JAMA cardiology JO - JAMA Cardiol VL - 2 IS - 10 N2 - Importance: In patients with left main coronary artery (LMCA) stenosis, coronary artery bypass grafting (CABG) has been the standard therapy for several decades. However, some studies suggest that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative. Objective: To compare the long-term safety of PCI with drug-eluting stent vs CABG in patients with LMCA stenosis. Data Sources: PubMed, Scopus, EMBASE, Web of Knowledge, and ScienceDirect databases were searched from December 18, 2001, to February 1, 2017. Inclusion criteria were randomized clinical trial, patients with LMCA stenosis, PCI vs CABG, exclusive use of drug-eluting stents, and clinical follow-up of 3 or more years. Data Extraction and Synthesis: Trial-level hazard ratios (HRs) and 95% CIs were pooled by fixed-effect and random-effects models with inverse variance weighting. Time-to-event individual patient data for the primary end point were reconstructed. Sensitivity analyses according to drug-eluting stent generation and coronary artery disease complexity were performed. Main Outcomes and Measures: The primary end point was a composite of all-cause death, myocardial infarction, or stroke at long-term follow-up. Secondary end points included repeat revascularization and a composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at long-term follow-up. Results: A total of 4 randomized clinical trials were pooled; 4394 patients were included in the analysis. Of these, 3371 (76.7%) were men; pooled mean age was 65.4 years. According to Grading of Recommendations, Assessment, Development and Evaluation, evidence quality with respect to the primary composite end point was high. Percutaneous coronary intervention and CABG were associated with a comparable risk of all-cause death, myocardial infarction, or stroke both by fixed-effect (HR, 1.06; 95% CI, 0.90-1.24; P = .48) and random-effects (HR, 1.06; 95% CI, 0.85-1.32; P = .60) analysis. Sensitivity analyses according to low to intermediate Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score (random-effects: HR, 1.02; 95% CI, 0.74-1.41; P = .89) and drug-eluting stent generation (first generation: HR, 0.90; 95% CI, 0.68-1.20; P = .49; second generation: HR, 1.19; 95% CI, 0.82-1.73; P = .36) were consistent. Kaplan-Meier curve reconstruction did not show significant variations over time between the techniques, with a 5-year incidence of all-cause death, myocardial infarction, or stroke of 18.3% (319 events) in patients treated with PCI and 16.9% (292 events) in patients treated with CABG. However, repeat revascularization after PCI was increased (HR, 1.70; 95% CI, 1.42-2.05; P < .001). Other individual secondary end points did not differ significantly between groups. Finally, pooled estimates of trials with LMCA stenosis tended overall to differ significantly from those of trials with multivessel coronary artery disease without left main LMCA stenosis. Conclusions and Relevance: Percutaneous coronary intervention and CABG show comparable safety in patients with LMCA stenosis and low to intermediate-complexity coronary artery disease. However, repeat revascularization is more common after PCI. SN - 2380-6591 UR - https://www.unboundmedicine.com/medline/citation/28903139/Percutaneous_Coronary_Intervention_vs_Coronary_Artery_Bypass_Grafting_in_Patients_With_Left_Main_Coronary_Artery_Stenosis:_A_Systematic_Review_and_Meta_analysis_ L2 - https://jamanetwork.com/journals/jamacardiology/fullarticle/10.1001/jamacardio.2017.2895 DB - PRIME DP - Unbound Medicine ER -