A comparison of coronary artery stenting with angioplasty for isolated stenosis of the proximal left anterior descending coronary artery: five year clinical follow up

Abstract

Background: Stent implantation for isolated stenosis of the proximal left anterior descending coronary artery (LAD) with preserved left ventricular function has been found to have a better clinical and angiographic outcome at one year than balloon angioplasty (PTCA).

Objective: To establish whether those results are maintained at five year follow up.

Methods: Patients were followed at least every six months. For those who died during follow up, data were obtained from medical records.

Main outcome measures: Freedom from death, non-fatal myocardial infarction, cerebrovascular accident, and repeated target lesion revascularisation. Secondary end points were revascularisation in a remote region and freedom from angina.

Results: Follow up was complete in all patients. At five years, the primary end point was reached more often by patients randomised to stent implantation than to PTCA (80% v 53%; odds ratio (OR) 0.29 (95% confidence interval (CI) 0.13 to 0.69); p = 0.0034). In the PTCA group, 35% of patients underwent target lesion revascularisation v 15% in the stent group (OR 0.33, 95% CI 0.13 to 0.80; p = 0.014). There was a trend towards increased mortality in the PTCA group than in the stent group (17% v 7%; OR 0.36, 95% CI 0.10 to 1.21; p = 0.098). No significant differences were found between PTCA and stent groups for non-fatal myocardial infarction (8% v 5%; OR 0.58, 95% CI 0.13 to 2.54; p = 0.46) or cerebrovascular accident (2% v 0%).

Conclusions: In patients with isolated stenosis of the proximal LAD, a five year clinical follow up confirmed a better outcome in those treated with stenting than with PTCA.

Figure 1

Kaplan-Meier event-free survival curves (defined as freedom from death, myocardial infarction, cerebrovascular accident, and target lesion revascularisation) of the two study groups at the five year follow up. At one year, the primary clinical end point was reached in 85% of the patients randomised to stent implantation (solid line) and in 65% of the patients randomised to PTCA (dashed line). The difference in the overall incidence of the primary end point, which was significant at one year, maintained its significance at five years (80% in the stent group v 53% in the PTCA group, p  =  0.0034).

Figure 2

Kaplan-Meier event-free survival for target lesion revascularisation: the reduced need for target lesion revascularisation was maintained in the stent group. Between 13 months and five years after the procedure, there were two additional cases of target lesion revascularisation in the PTCA group (3%) versus three (5%) in the stent group (p  =  0.99).