For patients who arereasonable surgical candidatesand who haveleft main coronary artery diseasewith associated three-vessel disease or high risk two-vessel disease,we recommend CABG rather than PCI; we also suggest CABG rather than PCI for most other patients with significant left main disease who are surgical candidates, following discussion of the relative risks and benefits.
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Randomized trials — The EXCEL, NOBLE, PRECOMBAT, and SYNTAX trials directly compared CABG with PCI with stenting.EXCEL and NOBLE are the most recent of these and were the only trials to use current generation drug eluting stents (DES) and thus these two trials have the greatest impact on our recommendations.
●The EXCEL trial randomly assigned 1905 patients with left main CAD of low or intermediate anatomical complexity (SYNTAX score of 32 or lower) to either PCI (with a goal of complete revascularization) with everolimus-eluting stents or CABG.
At three years,the primary end point, a composite of death from any cause, stroke, or MI, occurred at a similar rate in both groups (15.4 versus 14.7 percent; hazard ratio 1, 95% CI 0.79-1.26). There were no significant between-group differences in the three-year rates of the components of the primary end point. The secondary end point of death, stroke, or MI at 30 days occurred less often in patients in the PCI group (4.9 versus 7.9 percent) due mainly to a lower rate of MI.The secondary end point of death, stroke, MI, or ischemia driven revascularization at three years occurred more often with PCI (23.1 versus 19.1 percent.
At five years,the primary outcome occurred at a similar rate in both groups (22.0 versus 19.2 percent, respectively; difference 2.8 percentage points; odds ratio [OR] 1.19, 95% CI -0.9 to 6.5). Death from any cause, a secondary outcome, occurred more frequently in the PCI group (13.0 versus 9.9 percent; OR 1.38, 95% CI 0.2-6.1) due to a statistically nonsignificant greater number of noncardiovascular deaths.The rate of ischemia-driven revascularization was higher with PCI (16.9 versus 10.0 percent; OR 1.84, 95% CI 1.39-2.44).
REF. UpToDate 2020.01.17
