Do EXCEL and NOBLE translate into real world? A 5-year observational study of left main stem outcomes

Abstract

Aims: We aimed to uncover the 5-year real world outcomes of patients with significant left mainstem (LMS) disease managed with percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) or medical management.

Methods: We identified patients with LMS disease in 2012 and analysed baseline characteristics and outcomes in the following 5 years.

Results: 119 patients were identified, 62% (74) received CABG and 12% (14) received PCI and 26% (31) were medically managed. In PCI versus CABG, there was no significant difference in age and Synergy between PCI with Taxus and Cardiac Surgery score but there were significantly higher rates of pretreatment heart failure (ejection fraction 42%±10 vs 52%±13p=0.01). Overall major adverse cardiovascular event (MACE) being a composite of stroke, myocardial infarction (MI), target vessel revascularisation and all-cause mortality were not statistically different but numerically higher in the PCI group (36% (5) vs 23% (17) p=0.12). Medically managed patients were significantly older than those that were revascularised (PCI or CABG n=88; 75±11 vs 69±9 years p=0.01). They also had higher MACE (74% (23) vs 25% (22) p=0.000002) driven by MI (19% (6) vs 2% (1) p=0.01) and all-cause mortality (52% (16) vs 19% (17) p=0.01) compared with those with revascularisation.

Conclusions: The bleak outcomes of medical management in LMS disease are reflective findings from studies performed from several decades ago. Our findings show that there is still a role for PCI in the management of LMS disease in selected patients.

Keywords: coronary artery disease; coronary intervention (PCI); surgery-coronary bypass.

Figure 1

Boxplots to illustrate the differences in age groups between coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), medical management (Medical Mx).