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. 2008 Feb;24(2):121-6.
doi: 10.1016/s0828-282x(08)70567-1.

Outcomes of revascularization strategies for two-vessel coronary artery disease involving the proximal left anterior descending artery in an era of improved pharmacotherapy and stenting

Jaroslav Hubacek  1 , Sunil Kalla, P Diane Galbraith, Michelle M Graham, Merril L Knudtson, William A Ghali
Affiliations

Outcomes of revascularization strategies for two-vessel coronary artery disease involving the proximal left anterior descending artery in an era of improved pharmacotherapy and stenting

Jaroslav Hubacek et al. Can J Cardiol. 2008 Feb.

Abstract
in English, French

Background: The best therapeutic strategy for patients with double-vessel coronary artery disease and proximal left anterior descending artery involvement (2VD + pLAD) is not clear.

Objectives: To compare the survival experience of a cohort of cardiac catheterization patients with 2VD + pLAD based on chosen therapeutic strategy (medical management versus percutaneous coronary intervention [PCI] versus coronary artery bypass graft surgery [CABG]).

Methods: The authors identified and studied a total of 603 patients with 2VD + pLAD from all patients who underwent diagnostic coronary angiography in Alberta between January 1997 and May 1999. The primary end point was five-year survival from index catheterization for each of the treatment groups and from time of revascularization when the two revascularization strategies were compared.

Results: Risk-adjusted hazard ratios (HR) comparing cumulative five-year survival rates of patients treated medically, or with PCI or CABG indicated a survival benefit for patients treated with CABG (HR 0.24, 95% CI 0.11 to 0.54; P<0.001) and PCI (HR 0.43, 95% CI 0.24 to 0.77; P=0.003) compared with medical management. Meanwhile, a risk-adjusted comparison of revascularization strategies suggested a possible trend toward higher mortality for PCI-treated patients versus CABG-treated patients (HR 1.56, 95% CI 0.65 to 3.72; P=0.125).

Conclusions: The results of this registry-based observational study suggest a survival benefit from revascularization compared with medical management in patients with 2VD + pLAD. Furthermore, the authors found a trend toward better survival in CABG-treated patients compared with PCI-treated patients.

HISTORIQUE: On n’est pas certain de la meilleure stratégie thérapeutique pour les patients atteints d’une coronaropathie bitronculaire avec atteinte de l’artère descendante antérieure gauche proximale (C2T+DAGP).

OBJECTIFS: Comparer l’expérience de survie d’une cohorte de patients ayant subi un cathétérisme cardiaque avec C2T+DAGP d’après la stratégie thérapeutique choisie (prise en charge médicale, intervention coronaire percutanée [ICP] ou pontage aortocoronarien [PAC]).

MÉTHODOLOGIE: Les auteurs ont dépisté et étudié un total de 603 patients atteints d’une C2T+DAGP parmi l’ensemble des patients qui avaient subi une coronarographie diagnostique en Alberta entre janvier 1997 et mai 1999. Le paramètre ultime primaire était la survie cinq ans après le cathétérisme de référence dans chacun des groupes de traitement et à compter de la revascularisation lorsqu’on comparait les deux stratégies de revascularisation.

RÉSULTATS: Les risques relatifs rajustés (RRR) comparant les taux de survie au bout de cinq ans des patients traités par des médicaments, par ICP ou par PAC indiquent un avantage de survie chez les patients traités par PAC (RRR 0,24, 95 % IC 0,11 à 0,54; P<0,001) et par ICP (RRR 0,43, 95% IC 0,24 à 0,77; P=0,003) par rapport à la prise en charge médicale. De plus, une comparaison rajustée au risque des stratégies de revascularisation laisse supposer une tendance possible vers un taux de mortalité plus élevé chez les patients traités par ICP par rapport à ceux traités par PAC (RRR 1,56, 95 % IC 0,65 à 3,72; P=0,125).

CONCLUSIONS: Les résultats de cette étude d’observation de dossiers laissent supposer une meilleure survie après la revascularisation qu’à la prise en charge médicale chez les patients atteints d’une C2T+DAGP. De plus, les auteurs ont remarqué une tendance de meilleure survie chez les patients ayant subi une PAC par rapport à ceux traités par ICP.

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Figures

Figure 1
Figure 1
Identification of patients with two-vessel coronary artery disease (2VD) with proximal left anterior descending artery involvement (pLAD) from the Alberta Provincial Program for Outcome Assessment in Coronary Heart disease (APPROACH) database. CABG Coronary artery bypass graft surgery; PCI Percutaneous coronary intervention
Figure 2
Figure 2
Kaplan-Meier plot showing survival from time of diagnostic catheterization. Medical management (MM) versus coronary artery bypass graft surgery (CABG) P<0.001; MM versus PCI P=0.007; CABG versus percutaneous coronary intervention (PCI) P=0.037
Figure 3
Figure 3
Kaplan-Meier plot showing survival from time of revascularization procedure. Coronary artery bypass graft surgery (CAGB) versus percutaneous coronary intervention (PCI) P=0.048
Figure 4
Figure 4
Kaplan-Meier plot showing survival from time of revascularization procedure, with percutaneous coronary intervention (PCI)-treated patients separated into those with complete revascularization (CR) and incomplete revascularization (IR). Coronary artery bypass graft surgery (CABG) versus PCI CR P=0.31; CABG versus PCI IR P=0.027
Figure 5
Figure 5
Risk-adjusted hazard risk ratio (with 95% CI) for revascularization procedures versus medical therapy. CABG Coronary artery bypass graft surgery; PCI Percutaneous coronary intervention
Figure 6
Figure 6
Risk-adjusted hazard ratio (with 95% CI) for death in the percutaneous coronary intervention (PCI) group compared with the coronary artery bypass graft surgery (CABG) group. CR Complete revascularization; IR Incomplete revascularization
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