PCI Associated with Lower Stroke Risk Than CABG

MIAMI BEACH, FLA.—PCI may be associated with lower risk of stroke than CABG, according to pooled data from two meta-analyses.

The first analysis (JACC;2012;60:796-805) included 19 trials comparing PCI and CABG in which 8,744 patients were available for 30-day follow-up and 7,052 were available for 1-year follow-up.

Eighteen of the trials included in the analysis supported this association at 30-day follow-up (OR=2.94; 95% CI 1.69-5.09), Tullio Palmerini, MD, of Policlinico S. Orsola in Bologna, Italy, said at TCT 2012.

The finding also was observed at 1 year (see Figure).

Palmerini and colleagues conducted a second, unpublished meta-analysis to compare stroke rates observed in patients who underwent PCI vs. on-pump and off-pump CABG. The study included 83 trials that involved 22,729 patients.

At 30 days, PCI was associated with significantly lower rates of stroke than both off-pump CABG (OR=0.39; 95% CI 0.19-0.83) and on-pump CABG (OR=0.26; 95% CI 0.12-0.47).

Also, off-pump CABG was associated with significantly lower stroke rates than on-pump CABG (OR=0.67; 95% CI 0.41-0.95).

However, when researchers performed sensitivity analyses in which they stratified results from high-quality trials, trials with more than 100 patients and those with a definition for CEC adjudication of stroke, the difference in stroke risk between off-pump and on-pump CABG was markedly reduced and no longer significant. That finding suggests the initial findings may be driven by studies with a high likelihood of bias, Palmerini said.

Left main PCI

PCI for unprotected left main coronary artery disease remains rare in the United States, J. Matthew Brennan, MD, MPH, of Duke University Medical Center, said at TCT 2012.

Fewer than 5% of unprotected left main cases between 2004 and 2008 progressed to PCI, according to a review of the National Cardiovascular Data Registry. Most of those patients tended to be older, sicker and therefore at higher risk, Brennan said.

At 30 months, 60% of patients who underwent unprotected left main PCI experienced MACE and 45% died. MI occurred in 12%, and repeat revascularization occurred in 23%.

About 18% of unprotected left main cases during the study period were associated with IVUS use, which is considered the standard of care. IVUS use was associated with improved outcomes for MACE, death, MI and revascularization.

Also, single-stent technique — which has been shown to be superior to double stent technique — was used in approximately 40% of cases during the study period.

“The first clear implication is that, in the United States, there certainly is room for improvement,” Brennan said. “The results also highlight the importance of procedural reporting so we can understand what the outcomes are as well as the procedural details associated with unprotected left main PCI.”

The NCDR Cath PCI Registry included data from more than 700 hospitals that performed about 130,000 unprotected left main procedures during the study period. A majority of the centers performed fewer than 6 cases per year, Brennan said.