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Prevalence and non-invasive predictors of left main or three-vessel coronary disease: evidence from a collaborative international meta-analysis including 22 740 patients
  1. Fabrizio D'Ascenzo1,11,
  2. Davide Giacomo Presutti1,
  3. Elisa Picardi1,
  4. Claudio Moretti1,11,
  5. Pierluigi Omedè1,
  6. Filippo Sciuto1,
  7. Marco Novara1,
  8. Andrew T Yan2,
  9. Shaun Goodman2,
  10. Nitin Mahajan3,
  11. Masami Kosuge4,
  12. Alberto Palazzuoli5,
  13. Gwo-Ping Jong6,
  14. Hussain Isma'eel7,
  15. Matthew J Budoff7,
  16. Ronen Rubinshtein8,
  17. Henry Gewirtz9,
  18. Matthew J Reed10,
  19. Pierre Theroux11,
  20. Giuseppe Biondi-Zoccai10,11,
  21. Maria Grazia Modena10,
  22. Imad Sheiban1,
  23. Fiorenzo Gaita1
  1. 1Division of Cardiology, University of Turin, Turin, Italy
  2. 2Department of Medicine, Maimonides Medical Center, Brooklyn, New York, USA
  3. 3Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
  4. 4Department of Internal Medicine and Metabolic Diseases, Section of Cardiology, University of Siena, Siena, Italy
  5. 5Community Medical Research Center, Institute of Public Health, National Yang-Ming University, Yang-Ming, China
  6. 6American University of Beirut Medical Center, Beirut, Lebanon
  7. 7The Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-IIT, Haifa, Israel
  8. 8Department of Medicine, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  9. 9St Michael's Hospital, University of Toronto and Canadian Heart Research Centre, Toronto, Canada
  10. 10Division of Cardiology, University of Modena and Reggio Emilia, Modena, Italy
  11. 11Meta-analysis and Evidence based medicine Training in Cardiology (METCARDIO), Ospedaletti, Italy
  1. Correspondence to Dr Fabrizio D'Ascenzo, Division of Cardiology, University of Turin, S Giovanni Battista ‘Molinette’ Hospital, Corso Bramante 88-90, Turin 10126, Italy; fabrizio.dascenzo{at}


Background Left main disease (LMD) and three-vessel disease (3VD) have important prognostic value in patients with coronary artery disease. However, uncertainties still exist about their prevalence and predictors in patients with acute coronary syndrome (ACS) and also in patients with stable coronary disease. Thus the aim of this study was to perform an international collaborative systematic review and meta-analysis to appraise the prevalence and predictors of LMD and 3VD.

Methods Medline/PubMed were systematically searched for eligible studies published up to 2010, reporting multivariate predictors of LMD or 3VD. Study features, patient characteristics, and prevalence and predictors of LMD and 3VD were abstracted and pooled with random-effect methods (95% CIs).

Results 17 studies (22 740 patients) were included, 11 focusing on ACS (17 896 patients) and six on stable coronary disease (4844 patients). In the ACS subgroup, LMD or 3VD occurred in 20% (95% CI 7.2% to 33.4%), LMD in 12% (95% CI 10.5% to 13.5%), and 3VD in 25% (95% CI 23.1% to 27.0%). Heart failure at admission and extent of ST-segment elevation in lead aVR on 12-lead ECG were the most powerful predictors of LMD or 3VD. In the stable disease subgroup, LMD or 3VD was found in 36% (95% CI 18.5% to 48.8%), with the most powerful predictors being transient ischaemic dilation during the imaging stress test, extent of ST-segment elevation in aVR and V1 during the stress test, and hyperlipidaemia.

Conclusions This meta-analysis demonstrated that severe coronary disease—that is, LMD or 3VD—is more common in patients with ACS or stable coronary disease than generally perceived, and that simple and low-cost tools may help in the selection of the most appropriate therapeutic approach.

  • Left main
  • meta-analysis
  • multivariate predictors
  • multivessel disease
  • non-invasive assessment
  • systematic review
  • aorta
  • great vessels and trauma
  • cardiac function
  • electrocardiography
  • coronary stenting
  • population studies
  • remodelling of LV
  • inflammation

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  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Division of Cardiology, University of Turin.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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