Long-Term Outcomes Similar for CABG vs DES in Women with Left Main Disease

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Long-term outcomes in women with unprotected left main coronary artery disease (CAD) are comparable whether they receive percutaneous coronary intervention (PCI) with drug-eluting stents (DES) or coronary artery bypass grafting (CABG), according to a registry study published online February 3, 2014, ahead of print in the American Journal of Cardiology. However, CABG was associated with less long-term target vessel revascularization (TVR) and target lesion revascularization (TLR).

Researchers led by Alaide Chieffo, MD, of San Raffaele Scientific Institute (Milan, Italy), analyzed data from all women with unprotected left main CAD from the DELTA (Drug Eluting stent for LefT main coronary Artery disease) registry (n = 817). Patients were treated with either PCI with first-generation DES (n = 489) or CABG (n = 328) between April 2002 and April 2006 at 14 international centers.

Less Long-Term MACCE with CABG

After a median 1,148 days postprocedure, data from 175 propensity-matched pairs showed no difference in the primary endpoint (all-cause and cardiac death, MI, and stroke) between the PCI and CABG cohorts. However, CABG was associated with an advantage in MACCE (death, MI, stroke, TLR, and TVR), driven by less overall TVR and TLR (table 1).

Table 1. Long-Term Outcomes: PCI vs CABG

 

OR

95% CI

P Value

Primary Endpoint

0.711

0.387-1.308

0.273

All-cause Death

0.722

0.357-1.461

0.365

CV Death

1.100

0.455-2.660

0.832

MI

0.362

0.094-1.388

0.138

Stroke

1.200

0.359-4.007

0.767

TLR

0.253

0.092-0.703

0.008

TVR

0.185

0.079-0.432

< 0.001

MACCE

0.429

0.254-0.723

0.001


In-hospital results were similar, although a higher incidence of MI (OR 2.145; 95% CI 1.036-4.439; P = 0.040) and hence, MACCE (OR 2.000; 95% CI 1.030-3.883; P = 0.041) was seen in patients treated with CABG compared with PCI.

Within the PCI group, the long-term occurrence of MACCE was not affected by the use of triple or dual antiplatelet therapy (21.2% vs 31.7%; P = 0.235).

Evaluating the Specific Needs of Women

Dr. Chieffo and colleagues note that the advent of DES has brought improvements in overall clinical outcomes of PCI in patients with unprotected left main CAD, but they cite the unknown generalizability of current overall outcomes to women. The fact that “women typically present with coronary artery disease later than men with more unfavorable clinical and anatomical characteristics” coupled with the underrepresentation of women in related trials contribute to their uncertainty, the authors assert.

Regardless, the investigators report that the risk of the primary endpoint between PCI- and CABG-treated patients is similar to that of the overall population in the DELTA registry (HR 0.99; 95% CI 0.73-1.33; P = 0.97). Comparable TLR rates also raise questions concerning the results of previous studies indicating that female sex is an independent predictor of restenosis, they say.

Dr. Chieffo and colleagues note the limitations of the first-generation DES used in the registry, and also call for longer, randomized studies with a “larger representation of women and dedicated questions for sex-based issues . . . to better understand the treatment for this patient population.”

Study Details

Patients in DELTA who received PCI were treated with sirolimus- and paclitaxel-eluting stents.

The use of dual antiplatelet therapy (aspirin 100mg daily and clopidogrel 75mg daily or ticlopidine 250mg twice daily) was recommended for at least 12 months in all patients undergoing PCI. In the Korean center, cilostazol was additionally prescribed.

Note: Several study coauthors are faculty members of the Cardiovascular Research Foundation, which owns and operates TCTMD.

 


Source:
Buchanan GL, Chieffo A, Meliga E, et al. Comparison of percutaneous coronary intervention (with drug-eluting stents) versus coronary artery bypass grafting in women with severe narrowing of the left main coronary artery (from the W- DELTA [Women- Drug-Eluting stent for LefT main coronary Artery disease] registry). Am J Cardiol. 2014;Epub ahead of print.

 

 

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Disclosures
  • Dr. Chieffo reports no relevant conflicts of interest.

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