Abstract
Background The safety and efficacy of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for stable left main coronary artery disease (LMCAD) remains controversial. Methods Digital databases were searched to compare the major adverse cardiovascular and cerebrovascular events (MACCE) and its components. A random effect model was used to compute an unadjusted odds ratio (OR). Results A total of 43 studies (37 observational and 6 RCTs) consisting of 29,187 patients (PCI 13,709 and CABG 15,478) were identified. The 30-day rate of MACCE (OR, 0.56; 95% CI, 0.42–0.76; p = 0.0002) and all-cause mortality (OR, 0.52; 95% CI, 0.30–0.91; p = 0.02) was significantly lower in the PCI group. There was no significant difference in the rate of myocardial infarction (MI) (p = 0.17) and revascularization (p = 0.12). At 5 years, CABG was favored due to a significantly lower rate of MACCE (OR, 1.67; 95% CI, 1.18–2.36; p = <0.04), MI (OR, 1.67; 95% CI, 1.35–2.06; p = <0.00001), and revascularization (OR, 2.80; 95% CI, 2.18–3.60; p = <0.00001), respectively. PCI was associated with a lower overall rate of a stroke, while the risk of all-cause mortality was not significantly different between the two groups at 1- (p = 0.75), 5- (p = 0.72), and 10-years (p = 0.20). The Kaplan–Meier curve reconstruction revealed substantial variations over time; the 5-year incidence of MACCE was 38% with CABG, significantly lower than 45% with PCI (p = <0.00001). Conclusion PCI might offer early safety advantages, while CABG provides greater durability in terms of lower long-term risk of ischemic events. There appears to be an equivalent risk for all-cause mortality.
Highlights
Introduction e American College of Cardiology (ACC) and European Society of Cardiology (ESC) guidelines, updated in 2019, recommend coronary artery bypass grafting (CABG) in patients with stable left main coronary artery disease (LMCAD) with favorable coronary anatomy and low-predicted surgical mortality. e recommendations for percutaneous coronary intervention (PCI) vary depending upon the anatomical complexity of the unprotected LMCAD and patient complexity [1]. ese guidelines were based on summated evidence from six major clinical trials. e 3-year EXCEL trial which found PCI to be noninferior to CABG was the cornerstone of these recommendations [2]
Of concern was the use of a new definition of myocardial infarction (MI), reportedly favoring the PCI arm, in contravention of the previous protocol, which used the ird Universal Definition (UD) of MI, developed collaboratively by the ESC and American College ofCardiology (ACC). e European Association Journal of Interventional Cardiology for Cardio- oracic Surgery (EACTS) officially withdrew their support for ESC guidelines that endorse the use of coronary stents in many patients with LMCAD
226 articles were excluded based on our selection criteria. 43 articles (6 randomized controlled trials (RCTs) and 37 observational cohort studies (OCS)) were qualified for quantitative analysis
Summary
Introduction e American College ofCardiology (ACC) and European Society of Cardiology (ESC) guidelines, updated in 2019, recommend CABG in patients with stable LMCAD with favorable coronary anatomy and low-predicted surgical mortality (class IB). e recommendations for PCI vary depending upon the anatomical complexity (low, intermediate, and high) of the unprotected LMCAD and patient complexity [1]. ese guidelines were based on summated evidence from six major clinical trials. e 3-year EXCEL trial which found PCI to be noninferior to CABG was the cornerstone of these recommendations [2].Recently reported EXCEL’s 5-year results demonstrated continued noninferiority of PCI to CABG through 5 years for patients with left main CAD [3]. Cardiology (ACC) and European Society of Cardiology (ESC) guidelines, updated in 2019, recommend CABG in patients with stable LMCAD with favorable coronary anatomy and low-predicted surgical mortality (class IB). E 3-year EXCEL trial which found PCI to be noninferior to CABG was the cornerstone of these recommendations [2]. Reported EXCEL’s 5-year results demonstrated continued noninferiority of PCI to CABG through 5 years for patients with left main CAD [3]. Journal of Interventional Cardiology for Cardio- oracic Surgery (EACTS) officially withdrew their support for ESC guidelines that endorse the use of coronary stents in many patients with LMCAD. Is growing controversy and the fact that six previously conducted clinical trials have demonstrated conflicting results regarding the management of LMCAD have prompted this meta-analysis in an attempt to provide clarity on this issue Of concern was the use of a new definition of MI, reportedly favoring the PCI arm, in contravention of the previous protocol, which used the ird Universal Definition (UD) of MI, developed collaboratively by the ESC and ACC. e European Association
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