Alice in Wonderland of Drug-Eluting Stent for Unprotected Left Main Disease

Abstract

We read the recent meta-analysis by Jang et al 1 Jang J.S. Choi K.N. Jin H.Y. Seo J.S. Yang T.H. Kim D.K. Kim D.S. Urm S.H. Chun J.H. Kang S.J. Park D.W. Lee S.W. Kim Y.H. Lee C.W. Park S.W. Park S.J. Meta-analysis of three randomized trials and nine observational studies comparing drug-eluting stents versus coronary artery bypass grafting for unprotected left main coronary artery disease. Am J Cardiol. 2012; 110: 1411-1418 Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar of 3 randomized trials 2 Boudriot E. Thiele H. Walther T. Liebetrau C. Boeckstegers P. Pohl T. Reichart B. Mudra H. Beier F. Gansera B. Neumann F.J. Gick M. Zietak T. Desch S. Schuler G. Mohr F.W. Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol. 2011; 57: 538-545 Abstract Full Text Full Text PDF PubMed Scopus (321) Google Scholar , 3 Park S.J. Kim Y.H. Park D.W. Yun S.C. Ahn J.M. Song H.G. Lee J.Y. Kim W.J. Kang S.J. Lee S.W. Lee C.W. Park S.W. Chung C.H. Lee J.W. Lim D.S. Rha S.W. Lee S.G. Gwon H.C. Kim H.S. Chae I.H. Jang Y. Jeong M.H. Tahk S.J. Seung K.B. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011; 364: 1718-1727 Crossref PubMed Scopus (499) Google Scholar , 4 Kappetein A.P. Feldman T.E. Mack M.J. Morice M.C. Holmes D.R. Ståhle E. Dawkins K.D. Mohr F.W. Serruys P.W. Colombo A. Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J. 2011; 32: 2125-2134 Crossref PubMed Scopus (455) Google Scholar and 9 observational studies (with 5,079 patients) comparing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) disease. At 1-year follow-up, there were trends toward lower risk for death (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.45 to 1.02, p = 0.06) and the composite end point of death, myocardial infarction, or stroke (OR 0.70, 95% CI 0.49 to 1.00, p = 0.05) in the DES group compared to the CABG group. However, target vessel revascularization (TVR) was significantly higher in the DES group compared to the CABG group (OR 3.52, 95% CI 2.72 to 4.56, p <0.00001). The investigators concluded that PCI with DES was associated with favorable outcomes for mortality and the composite end point of death, myocardial infarction, or stroke and with a higher risk for TVR compared to CABG in patients with ULMCA disease. However, the investigators abstracted unadjusted dichotomous data (events/total) in unmatched groups from observational studies except for the Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization (MAIN-COMPARE) study 5 Park D.W. Seung K.B. Kim Y.H. Lee J.Y. Kim W.J. Kang S.J. Lee S.W. Lee C.W. Park S.W. Yun S.C. Gwon H.C. Jeong M.H. Jang Y.S. Kim H.S. Kim P.J. Seong I.W. Park H.S. Ahn T. Chae I.H. Tahk S.J. Chung W.S. Park S.J. Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. J Am Coll Cardiol. 2010; 56: 117-124 Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar which consisted propensity score-matched groups. Unadjusted risk estimates in observational studies must be highly biased. Thus, extracting not “unadjusted” but “adjusted” risk estimates from observational studies, we performed an updated meta-analysis of PCI with DES versus CABG for the prevention of late death and major adverse cardiac and cerebrovascular events (MACCEs; a composite of death, myocardial infarction, or stroke) in ULMCA disease. All analyses were conducted using Review Manager version 5.1 (Nordic Cochrane Centre, Copenhagen, Denmark) and Comprehensive Meta-Analysis version 2 (Biostat, Englewood, New Jersey). Meta-Analysis of Three Randomized Trials and Nine Observational Studies Comparing Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery DiseaseAmerican Journal of CardiologyVol. 110Issue 10PreviewClinical outcomes for unprotected left main coronary artery (ULMCA) disease between coronary artery bypass grafting (CABG) and drug-eluting stents (DESs) remain controversial. We aimed to compare the safety and efficacy of percutaneous coronary intervention (PCI) using DESs with CABG in patients with ULMCA disease. Databases were searched for clinical studies that reported outcomes after PCI with DESs and CABG for treatment of ULMCA disease. End points of this meta-analysis were mortality; composite of death, myocardial infarction (MI), or stroke; and target vessel revascularization at 1-year follow-up. Full-Text PDF