Comparison of medicine alone, coronary angioplasty, and left internal mammary artery–coronary artery bypass for one-vessel proximal left anterior descending coronary artery disease

doi:10.1016/S0002-9149(00)01235-2

The American Journal of Cardiology

Volume 86, Issue 12, 15 December 2000, Pages 1322-1326

https://doi.org/10.1016/S0002-9149(00)01235-2 Get rights and content

Abstract

Despite the deleterious and sometimes catastrophic consequences of proximal left anterior descending (LAD) artery occlusion, there is a paucity of data to guide the treatment of patients with such disease. Our aim was to describe outcomes with medical therapy, angioplasty, or left internal mammary artery (LIMA) bypass grafting in patients with 1-vessel, proximal LAD disease. We retrospectively analyzed prospectively collected data from 1,188 patients first presenting only with proximal LAD disease at 1 center over 9 years. We assessed the rates of death, acute myocardial infarction, and repeat intervention by initial treatment over a median 5.7 years of follow-up. Patients undergoing angioplasty or LIMA bypass were more often men and had progressive or unstable angina; those receiving medical therapy had a lower median ejection fraction. Both revascularization procedures offered slightly better adjusted survival versus medicine (hazard ratio for angioplasty, 0.82; 95% confidence interval, 0.60 to 1.11; hazard ratio for bypass, 0.74; 95% confidence interval, 0.44 to 1.23). Bypass, but not angioplasty, was associated with significantly fewer composite end point events (death, infarction, or reintervention, p <0.0001), and angioplasty was associated with a higher composite event rate than bypass or medical therapy (p <0.0001 and p = 0.0003, respectively). The initial advantages of bypass and medicine over angioplasty diminished over time; angioplasty became more advantageous than medicine after 1 year (p = 0.05) and not significantly different from bypass. Treatment of 1-vessel, proximal LAD disease with medicine, angioplasty, or LIMA bypass resulted in comparable adjusted survival. However, LIMA bypass alone reduced the long-term incidence of infarctions and repeat procedures.

Section snippets

Patients

Between April 1, 1986, and February 28, 1994, 1,218 patients with proximal LAD disease undergoing a first diagnostic angiogram were identified. Of these, 754 underwent angioplasty, 149 underwent LIMA bypass (another 21 had vein grafts, which were excluded from analysis), and the remainder (n = 294) underwent no procedures within the first 30 days after angiography. These 1,197 eligible patients had coronary syndromes ranging from stable angina to evolving AMI, and reflected left ventricular

Results

Fewer women underwent surgery than did those taking other treatments (Table 1). Patients who had undergone angioplasty or LIMA grafting more often had either progressive or unstable angina than did medically treated patients. Risk factor profiles were similar except for more diabetics in the medical and angioplasty groups. The greatest differences among the groups occurred in clinical measures of myocardial damage. On average, medically treated patients had a longer duration of symptoms, more

Discussion

In this observational comparison of patients with 1-vessel, proximal LAD disease, surgical and percutaneous revascularizations were associated with nonsignificant survival advantages compared with medical therapy after adjustment for baseline clinical and angiographic differences. Further, LIMA bypass (but not angioplasty) was associated with a significant, long-term reduction in a composite of adverse cardiac events, largely driven by fewer repeat interventions. Angioplasty resulted in

Acknowledgements

We thank Pat French and A. J. Mayhew for editorial assistance, and Anthony Doll for graphic assistance.

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2019, Journal of the American College of Cardiology
Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR).
The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial.
MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex.
A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06).
iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.
The Influence of Lesion Location on the Diagnostic Accuracy of Adenosine-Free Coronary Pressure Wire Measurements
2016, JACC: Cardiovascular Interventions
Citation Excerpt :
Nevertheless, cFFR still provides the best diagnostic accuracy among the adenosine-free indices, regardless of the lesion location. These results highlight the importance of inducing maximal hyperemia with adenosine to most accurately assess the functional severity of LM/pLAD lesions, which are prognostically the most important stenoses (23,24). Several studies have reported the discordance that can occur between the angiographic appearance of a stenosis and its FFR value.
This work compares the diagnostic performance of adenosine-free coronary pressure wire indices based on lesion location.
Several adenosine-free coronary pressure wire indices have been proposed to assess the functional significance of coronary artery lesions; however, there is a theoretical concern that lesion location and the mass of perfused myocardium may affect diagnostic performance.
A total of 763 patients were prospectively enrolled from 12 institutions. Fractional flow reserve (FFR) and contrast-based FFR (cFFR) were obtained during adenosine-induced maximal hyperemia and contrast-induced submaximal hyperemia respectively, whereas the instantaneous wave-free ratio (iFR) and distal pressure/aortic pressure (Pd/Pa) were obtained at rest. Using an FFR of ≤0.80 as a reference standard, the diagnostic accuracy of each index was compared based on lesion location (left main or proximal left anterior descending artery [LM/pLAD] compared with other lesion locations).
The median FFR, cFFR, iFR, and Pd/Pa were 0.81 (interquartile range [IQR]: 0.74 to 0.87), 0.86 (IQR: 0.79 to 0.91), 0.90 (IQR: 0.85 to 0.94), and 0.92 (IQR: 0.88 to 0.95), respectively. The cFFR, iFR, and Pd/Pa were less accurate in LM/pLAD compared with other lesion locations (cFFR: 80.3% vs. 87.8%; iFR: 73.3% vs. 81.8%; Pd/Pa: 71.4% vs. 81.1%, respectively). By receiver-operating characteristics curve analysis, cFFR provided better diagnostic accuracy than resting indices regardless of lesion location (p ≤0.0001 vs. iFR and Pd/Pa for both groups).
The cFFR, iFR, and Pd/Pa are less accurate in LM/pLAD compared with other lesion locations, likely related to the larger amount of myocardium supplied by LM/pLAD. Nevertheless, cFFR provides the best diagnostic accuracy among the adenosine-free indices, regardless of lesion location.
Meta-analysis of minimally invasive coronary artery bypass versus drug-eluting stents for isolated left anterior descending coronary artery disease
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To compare the outcomes between minimally invasive coronary artery bypass (MINI-CAB) and drug-eluting stent (DES) implantation for isolated left anterior descending artery disease.
Randomized and observational comparative publications were identified using MEDLINE and Google Scholar databases (January 2003 to December 2013). Studies without outcomes data, without DES use, or using conventional bypass surgery were excluded. The outcomes of interest were cardiac death, myocardial infarction, target vessel revascularization, and periprocedural stroke. Data were compared using the Mantel-Haenszel methods and are presented as odds ratios (ORs), 95% confidence intervals (CIs), and number needed to treat.
From 230 publications, we identified 4 studies (2 randomized and 2 observational) with 941 patients (478 had undergone MINI-CAB and 463 DES implantation). The incidence of target vessel revascularization at maximum follow-up (range, 6-60 months) was significantly lower in the MINI-CAB group (OR, 0.16; 95% CI, 0.08-0.30; P < .0001; number needed to treat, 13). The incidence of cardiac mortality and MI was similar between the MINI-CAB and DES groups during follow-up (OR, 1.05; 95% CI, 0.44-2.47; and OR, 0.83; 95% CI, 0.43-1.58, respectively). In addition, a similar incidence of periprocedural death (OR, 0.85; 95% CI, 0.21-3.47; P = .82), myocardial infarction (OR, 0.98; 95% CI, 0.38-2.58; P = .97), and stroke (OR, 1.36; 95% CI, 0.28-6.70; P = .70) was observed between the 2 treatment modalities.
Given the available evidence, MINI-CAB will result in lower target vessel revascularization rates but otherwise similar clinical outcomes compared with DESs in patients with left anterior descending artery disease.
High-sensitive Troponin, B-type natriuretic peptide and coronary angiogram findings in patients with non ST-segment elevation acute coronary syndrome
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The effect of left internal mammary artery utilization on short-term outcomes after coronary revascularization
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Citation Excerpt :
By making this information available to all surgeons in the state of Washington, this study will hopefully encourage greater usage of LIMA grafts, at levels equivalent to the national mean in all patient subgroups, in an effort to improve clinical outcomes for coronary revascularization. ([9,10,11,12]
The purpose of this study was to determine whether use of the left internal mammary artery (LIMA) during coronary revascularization influences short-term morbidity in all patients undergoing revascularization, as well as in patients over the age of 75 years, female patients, and patients with diabetes. The study also explored variability in the utilization of LIMA grafts across an entire state.
Using the Clinical Outcomes Assessment Program (COAP) of the state of Washington, procedural outcomes were compared for patients receiving and patients not receiving LIMA grafts as part of revascularization procedures from January 1, 1999 to December 31, 2000. Mortality and major complications were examined, both as unadjusted rates and after adjusting for baseline patient risk factors.
A total of 16 centers performed 8,797 nonemergent coronary artery revascularizations, including 81.7% with LIMA grafts. The use of a LIMA graft was associated with a significantly lower mortality (3.7% No LIMA vs 1.6% LIMA), as well as decreases in ventricular arrhythmias, need for postoperative dialysis, need for transfusions, ventilator dependence, and length of hospital stay. These trends were true for the population as a whole as well as for all subgroups analyzed, and they persisted after correcting for differences in comorbid conditions. In addition, there was wide variability in the use of LIMA grafts from center to center in the state.
The use of LIMA grafts for coronary revascularization is associated with decreased mortality and morbidity. Despite these advantages, there is great variability in its application across the state of Washington.
Off-pump surgery may have some long-term benefits over percutaneous coronary angioplasty with stenting in proximal left anterior descending coronary artery disease
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Comparison of medicine alone, coronary angioplasty, and left internal mammary artery–coronary artery bypass for one-vessel proximal left anterior descending coronary artery disease

Abstract

Section snippets

Patients

Results

Discussion

Acknowledgements

Lancet

J Thorac Cardiovasc Surg

Am Heart J

Am J Cardiol

Lancet

J Am Coll Cardiol

J Chronic Dis

Coronary artery surgery study (CASS)a randomized trial of coronary artery bypass surgery: survival data

Circulation

Twelve-year follow-up of survival in the randomized European Coronary Surgery Study

N Engl J Med