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European Heart Journal Advance Access originally published online on August 30, 2009
European Heart Journal
2009 30(19):2308-2317; doi:10.1093/eurheartj/ehp353
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org

Unprotected left main revascularization in patients with acute coronary syndromes

Gilles Montalescot1,*, David Brieger2, Kim A. Eagle3, Frederick A. Anderson, Jr4, Gordon FitzGerald4, Michael S. Lee5, Ph. Gabriel Steg6, Álvaro Avezum7, Shaun G. Goodman8, Joel M. Gore and for the GRACE Investigators{dagger}

1 Institut de Cardiologie, Bureau 2-236, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47 Blvd de l'Hôpital, 75013 Paris, France
2 Concord Hospital, Sydney, NSW, Australia
3 University of Michigan Cardiovascular Center, Ann Arbor, MI, USA
4 Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
5 UCLA Medical Center, University of California, Los Angeles School of Medicine, Los Angeles, CA, USA
6 Department of Cardiology, INSERM U-698, Université Paris 7 and Assistance Publique - Hôpitaux de Paris, Paris, France
7 Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
8 Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada

Received 16 July 2009; revised 11 August 2009; accepted 12 August 2009; online publish-ahead-of-print 30 August 2009.

* Corresponding author. Tel: +33 1 42 16 30 06, Fax: +33 1 42 16 29 31, Email: gilles.montalescot{at}psl.aphp.fr

See page 2295 for the commentary on this article (doi:10.1093/eurheartj/ehp354)

Aims: In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary disease (ULMCD) has been little studied. The objectives of the present study were to describe the practice of ULMCD revascularization in ACS patients and its evolution over an 8-year period, analyse the prognosis of this population and determine the effect of revascularization on outcome.

Methods and results: Of 43 018 patients enrolled in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007, 1799 had significant ULMCD and underwent percutaneous coronary intervention (PCI) alone (n = 514), coronary artery bypass graft (CABG) alone (n = 612), or no revascularization (n = 673). Mortality was 7.7% in hospital and 14% at 6 months. Over the 8-year study, the GRACE risk score remained constant, but there was a steady shift to more PCI than CABG over time. Patients undergoing PCI presented more frequently with ST-segment elevation myocardial infarction (STEMI), after cardiac arrest, or in cardiogenic shock; 48% of PCI patients underwent revascularization on the day of admission vs. 5.1% in the CABG group. After adjustment, revascularization was associated with an early hazard of hospital death vs. no revascularization, significant for PCI (hazard ratio (HR) 2.60, 95% confidence interval (CI) 1.62–4.18) but not for CABG (1.26, 0.72–2.22). From discharge to 6 months, both PCI (HR 0.45, 95% CI 0.23–0.85) and CABG (0.11, 0.04–0.28) were significantly associated with improved survival in comparison with an initial strategy of no revascularization. Coronary artery bypass graft revascularization was associated with a five-fold increase in stroke compared with the other two groups.

Conclusion: Unprotected left main coronary disease in ACS is associated with high mortality, especially in patients with STEMI and/or haemodynamic or arrhythmic instability. Percutaneous coronary intervention is now the most common revascularization strategy and preferred in higher risk patients. Coronary artery bypass graft is often delayed and performed in lower risk patients, leading to good 6-month survival. The two approaches therefore appear complementary.

Key Words: Left main disease • Acute coronary syndrome

{dagger} The Complete List of the GRACE Investigators and Coordinators can be found at www.outcomes.org/grace.


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