PCI for Left Main Disease Uncommon in US Clinical Practice
Download this article's Factoid in PDF (& PPT for Gold Subscribers)
Capturing a period of time prior to publication of the SYNTAX trial, a large registry report appearing in the February 14, 2012, issue of the Journal of the American College of Cardiology (ACC) shows that percutaneous coronary intervention (PCI) was rarely used to treat unprotected left main coronary artery disease in US clinical practice. According to the study, PCI was reserved for those at high procedural risk, while the elderly, in particular, suffered the highest complication rates from the procedure.
ACC/American Heart Association revascularization guidelines upgraded left main PCI from a class III to a class IIb recommendation in 2008. And after the SYNTAX trial, which helped refine patient selection between PCI and CABG in patients with complex disease, the procedure was given a class IIa recommendation.
For the new study, researchers led by J. Matthew Brennan, MD, MPH, of the Duke Clinical Research Institute (Durham, NC), looked at trends in US practice by studying 131,004 patients in the National Cardiovascular Data Registry Catheterization PCI registry treated for left main disease between January 1, 2004, and December 31, 2008 (prior to SYNTAX, which was published in February 2009). Of these, only 5,627 (4.3%) received PCI, the majority of whom (4,085; 72.6%) were 65 years or older. A subgroup of the elderly patients (2,765; 69%) was followed by linking to Medicare inpatient claims data.
Left Main PCI Rare, Reserved for Emergencies
While PCI for left main disease was uncommon, it was generally reserved for those with either a high burden of noncardiac disease or emergent clinical presentations. Those receiving PCI were older with higher levels of renal failure, PAD, and stroke than those who did not receive PCI for left main disease (CABG or medical management). The indications for patients receiving PCI were more often NSTEMI (24.8% vs. 18.7%; P < 0.001) and STEMI (13.4% vs. 9.4%; P < 0.001) compared with those who did not receive PCI. Stented patients also had higher levels of pre-procedural shock, IABP use, and bifurcation lesions.
Overall, 95% of left main patients receiving PCI survived to hospital discharge. However, patients receiving PCI had a higher in-hospital mortality rate compared with non-PCI patients (13.1% vs. 4.6%; P < 0.0001). In-hospital mortality was associated with clinical urgency, with higher death rates observed among emergent/salvage cases (45.1%) vs. elective (2.9%) cases and high (26.0%) vs. low (3.2%) pre-procedural logistic EuroScore.
By 30 months, 42.7% of elderly left main PCI patients had died, while 57.9% experienced death, MI, or revascularization. Patients receiving DES had lower 30-month mortality compared with BMS (39.6% vs. 52.7%; adjusted HR 0.84; 95% CI 0.73-0.96), but composite events were equivalent (adjusted HR 0.95; 95% CI 0.84-1.06). DES were used in the majority of lower-urgency procedures (81.8%), while DES and BMS use was similar in high-urgency procedures after 2006.
Sickest Patients, Elderly at Highest Risk
Patients with the highest rates of major adverse events at 30 months included those with high vs. low logistic EuroScore values (76.6% vs. 53.9%; P < 0.001), high vs. low clinical urgency (74.2% vs. 52.8%; P < 0.001), and bifurcation vs. ostial or mid-body lesions (64.8% vs. 54.7%; P < 0.001).
Through 2008, most centers performed less than 1 left main PCI per month, although the overall proportion of PCI-treated patients rose slightly over the course of the study (3.8% to 4.9%; P < 0.0001).
Left main PCI “remains a relatively uncommon procedure at most US centers and is primarily reserved for those at high risk for [CABG],” the researchers conclude. “Poor outcomes following percutaneous revascularization in elderly [left main] patients are common and are likely influenced by both patient and procedural characteristics.”
Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), indicated he is not surprised by the findings. “Left main PCI is performed rarely, much more rarely than in Europe,” he told TCTMD in a telephone interview. “When you do it in moribund people, the results are not so good. But they’re dying not because of the PCI—more than 95% left the hospital—they’re dying because they’re sick and old and have many comorbidities.”
Rates Rise Since SYNTAX
Dr. Brener noted that for most of the study period, left main PCI was still a class III recommendation. “So it remained flat over the years,” he observed, adding that the overall low number of cases per year was unexpected. For instance, according to the findings, out of more than 21,000 cases of left main disease in 2005, only about 820 were treated with PCI. “That’s pretty low. I do about 30 a year just myself.”
Since the SYNTAX trial, rates have changed, although not dramatically. “Rates of PCI for left main have risen, but I don’t think it’s drastically different, as in 10 times more,” Dr. Brener said. “I would presume it’s probably about 50% more.”
He stressed that the most recent guidelines are correct in identifying certain subsets of patients who are good candidates for left main PCI. Dr. Brener noted that for comparison’s sake, he would like to see data about the rates of left main PCI in Europe alongside the US results. “They’re doing it substantially more in Europe; it’s like night and day,” he said. “But it’s being done because it actually works very well and the results are pretty good in experienced hands.”
Source:
Brennan JM, Dai D, Patel MR, et al. Characteristics and long-term outcomes of percutaneous revascularization of unprotected left main coronary artery stenosis in the United States. A report from the National Cardiovascular Data Registry, 2004 to 2008. J Am Coll Cardiol. 2012;59:648-654.
Disclosures:
- The study was sponsored by the Agency for Healthcare Research and Quality, US Department of Health and Human Services
- Drs. Brennan and Brener report no relevant conflicts of interest.
Related Stories:
Jason R. Kahn, the former News Editor of TCTMD, worked at CRF for 11 years until his death in 2014…
Read Full Bio
Comments