Comparative Outcomes After Unprotected Left Main Stem Percutaneous Coronary Intervention: A National Linked Cohort Study of 5,065 Acute and Elective Cases From the BCIS Registry (British Cardiovascular Intervention Society)

doi:10.1016/j.jcin.2014.03.005

JACC: Cardiovascular Interventions

Volume 7, Issue 7, July 2014, Pages 717-730

https://doi.org/10.1016/j.jcin.2014.03.005 Get rights and content

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Objectives

The goal of this study was to report outcomes from percutaneous coronary intervention (PCI) to an unprotected left main stem (UPLMS) stenosis according to presenting syndrome, including ST-segment elevation myocardial infarction (STEMI), non–ST-segment elevation acute coronary syndrome (NSTEACS), and chronic stable angina (CSA).

Background

There are no published whole-country data concerning patient outcomes following PCI to UPLMS.

Methods

This study is a prospective national cohort study using data from the British Cardiovascular Intervention Society (BCIS) registry from January 1, 2005, through December 31, 2010.

Results

Of 5,065 patients having PCI to an UPLMS, 784 (15.5%) presented with STEMI, 2,381 (47.0%) with NSTEACS, and 1,900 (37.5%) with CSA. Crude 30-day and 1-year mortality rates were STEMI: 28.3% and 37.6%, NSTEACS: 8.9% and 19.5%, and CSA: 1.4% and 7.0%, respectively. Unadjusted in-hospital major adverse cardiovascular and cerebrovascular event rates were STEMI: 26.6%, NSTEACS: 6.6%, and CSA: 3.3%. Risk of 30-day mortality was much greater for STEMI and NSTEACS patients than CSA (STEMI adjusted odds ratio [aOR]: 29.45, 95% confidence interval [CI]: 19.37 to 44.80, NSTEACS aOR: 6.45, 95% CI: 4.27 to 9.76). More than 40% of patients presenting with STEMI had cardiogenic shock, in whom mortality was higher than in STEMI cases without shock (30 days: 52.0% vs. 11.7%, 1 year: 61.1% vs. 20.9%). Radial access, compared with the femoral approach, was associated with a lower risk of 30-day mortality (STEMI aOR: 0.37, 95% CI: 0.21 to 0.62; NSTEACS aOR: 0.66, 95% CI: 0.45 to 0.97).

Conclusions

More than one-half of the patients who received UPLMS PCI were acute where outcomes were much worse than elective cases. Cardiogenic shock is common in STEMI patients, of whom more than one-half die at 30 days. The radial approach was associated with reduced early mortality in acute cases.

Key Words

acute myocardial infarction

adjusted odds ratio(s)

chronic stable angina

confidence interval(s)

mortality

multiple imputation

NSTEACS

outcome

percutaneous coronary intervention

STEMI

survival

unprotected left main stem

Abbreviations and Acronyms

aOR

adjusted odds ratio

BCIS

British Cardiovascular Intervention Society

CABG

coronary artery bypass grafting

confidence interval

CSA

chronic stable angina

IABP

intra-aortic balloon pump

IVUS

intravascular ultrasound

LVSD

left ventricular systolic dysfunction

MACCE

major adverse cardiovascular and cerebrovascular event(s)

NSTEACS

non–ST-segment elevation acute coronary syndrome

PCI

percutaneous coronary intervention

STEMI

ST-segment elevation myocardial infarction

UPLMS

unprotected left main stem

Cited by (0)

: The British Cardiovascular Intervention Society (BCIS) registry is funded by the Health Quality Improvement Partnership (HQIP). Dr. Gale is funded by the National Institute for Health Research (NIHR/CS/009/004) as a Clinician Scientist and Honorary Consultant Cardiologist. Dr. Baxter is supported by the Higher Education Funding Council for England (HEFCE). Dr. Curzon has received unrestricted grants from Haemonetics, St. Jude Medical, and Medtronic; and has been a consultant and on the Speakers’ Bureaus of Haemonetics, Boston Scientific, St. Jude Medical, Daiichi Sankyo, and Abbott Vascular. The National Institute for Cardiovascular Outcomes Research (NICOR), which hosts the BCIS registry (Ref: NIGB: ECC 1-06 (d)/2011), has support under section 251 of the National Health Service (NHS) Act 2006. Ethical approval was not required under NHS research governance arrangements for the project. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.