Is an Appropriate Revascularization Selected for Unprotected Left Main Coronary Artery Disease?

Abstract

Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp 65%). In patients with low or intermediate SYNTAX scores, the rate of serious cardiovascular events was not different between PCI and CABG. However, the risk of events was markedly higher in the PCI group with high SYNTAX scores compared with the CABG group.In this issue of the Journal, Shiomi et al 6 report the 5-year extended follow-up data. The cumulative 5-year incidence of the primary endpoints (death, MI and stroke) was significantly higher in the PCI group than in the CABG group (34.5 vs. 24.1%, P<0.001). The adjusted hazard ratio (HR) for the primary endpoint in the PCI group was 1.48 (95% confidence interval (CI) 1.07-1.93, P=0.02). No difference was observed in the adjusted HR for all-cause mortality between the groups (adjusted HR 1.32, 95% CI 0.90-1.93, P=0.16), whereas the adjusted HR for the following outcomes were significantly higher in the PCI group (cardiac death: adjusted HR 2.00, 95% CI 1.10-3.63, P=0.02; MI: adjusted HR 2.25, 95% CI 1.04-4.88, P=0.04; revascularization: adjusted HR 4.31, 95% CI 2.97-6.26, P<0.001). Subgroup analyses stratified by SYNTAX score (low: <23, intermediate: 23-32, high: >32) were performed for 92.7% of the whole study population. The adjusted HR for the primary endpoint was not different in patients with a low or intermediate SYNTAX score. The event rate in patients with a high SYNTAX score was significantly higher in the PCI group (adjusted HR 2.09, 95% CI 1.26-3.46, P=0.004). The results from this relatively large-scale, prospecmproved devices related to percutaneous coronary intervention (PCI) and increased operator skill have expanded the indications for PCI to a wide range of coronary artery disease (CAD), such as multivessel CAD or unprotected left main CAD (ULMCAD). Specifically, ULMCAD was previously a contraindication for PCI. Several recent clinical trials demonstrated favorable results following PCI for the treatment of ULMCAD compared with coronary artery bypass grafting (CABG). 1-3 This evidence prompted updating of the guidelines for the treatment of ULMCAD. However, the number of patients in those trials was not sufficient and, furthermore, most of the trials were conducted in Western countries. Therefore, it is of great interest to examine the clinical outcomes of patients with ULMCAD treated with PCI or CABG in a Japanese population, which differs from populations in Western countries regarding dietary habits, various comorbid diseases, and the incidence of CAD. 4 Article p 1282Previously, Shiomi and colleagues reported the 3-year follow-up data from a large-scale Japanese database, the CREDO-Kyoto PCI/CABG Registry. 5 The authors reported that the 3-year composite endpoint of all-cause death, myocardial infarction (MI) and stroke was comparable between PCI with drug-eluting stent (DES) and CABG (off-pump CABG; IThe opinions expressed in this article are not necessarily those of the editors or of the Japanese Circulation Society.