PCI and CABG for left main disease have equal outcomes at 5 years


Background: While PCI with drug-eluting stents has become more accepted as treatment for some patients with left main disease, long-term outcomes from randomized control trials comparing PCI with CABG have yet to be clearly established.

Study design: International, open-label, multicenter, randomized trial.

Setting: A total of 126 sites in 17 countries.

Synopsis: Patients with low or intermediate anatomical complexity with 70% visual stenosis of the left main coronary artery or 50%-70% stenosis by noninvasive testing were randomized to either PCI (948) or CABG (957). Dual-antiplatelet therapy was given to PCI patients and aspirin to CABG patients. At 5 years there was no significant difference in the rate of the composite of death, stroke, or myocardial infarction (22.0% with PCI vs. 19.2% with CABG; difference, 2.8 percentage points; 95% CI, –0.9 to 6.5; P = .13). This was consistent across subgroups.

There were numerical differences in nonpowered secondary outcomes that may represent effects but should be interpreted cautiously: ischemia-driven revascularization (16.9% with PCI vs. 10% with CABG), transient ischemic attack plus stroke (3.3% with PCI vs. 5.2% with CABG), and death from any cause (3% with PCI vs. 9.9% with CABG). There was no significant difference in cardiovascular events, MI, or stroke.

One interesting limitation was that patients who had PCI were more commonly on dual-antiplatelet therapy and angiotensin converting–enzyme inhibitors, whereas CABG patients were more often on beta-blockers, diuretics, anticoagulants, and antiarrhythmics.

Bottom line: PCI and CABG treatments for left main disease have no significant difference in the composite outcome of death, stroke, or MI at 5 years.

Citation: Stone GW et al. Five-year outcomes after PCI or CABG for left main coronary disease. N Engl J Med. 2019;381:1820-30.

Dr. Horton is a hospitalist and clinical instructor of medicine at the University of Utah, Salt Lake City.

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