A large study of nearly two thousand patients with left main coronary artery disease (LMCAD) has confirmed to scientists that the treatment of this disease is just as effective with a drug-eluting stent as it is with coronary artery bypass graft (CABG) surgery.
In the past, scientists have studied the potential for drug-eluting stents as a less-invasive alternative to CABG surgery, but now lead author Gregg W. Stone, MD, of the recent New England Journal of Medicine
study says that “stents have gotten better, and so has cardiac bypass surgery. That required us to take a fresh look at the relative safety and effectiveness of the two approaches."
Stone and his team, cardiologists and cardiac surgeons from 126 centers in 17 countries, randomized 1,905 patients with LMCAD and low or intermediate coronary artery disease in other coronary arteries to receive either a drug-eluting stent that releases an antiproliferative agent called everolimus or CABG surgery, and they followed the patients for at least two years to observe their health outcomes. The large, international study is called Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL).
The results showed around fifteen percent of patients from both groups had a heart attack, stroke, or died within three years, Stone reported. "In other words, stents were equally effective as bypass surgery."
Drug-eluting stents are installed in the diseased artery through a catheter, making it a much less-invasive option than CABG. The stents release antiproliferative medications to prevent the artery from becoming blocked again after the procedure. Stone and colleagues believe that this option is especially appropriate for patients with LMCAD without extensive blockages in other coronary arteries.
The research team also focused on health outcomes of patients from the two randomized groups within the first 30 days following the procedure, the time period in which the most serious complications are most likely to occur. The patients who received drug-eluting stents showed a clear advantage: they had a three percent lower incidence of death, stroke, heart attack, or revascularization, and fewer stent patients had major bleeding, infections, kidney failure, or severe abnormal heart rhythms.
Stone and his team have yet to study patients with LMCAD and extensive blockages in the rest of the coronary arteries; all of the participants from this study had only mild blockages in their other coronary arteries, so they still recommend coronary artery bypass graft surgery for patients with more serious blockages.
"While bypass is still considered a more durable repair, patients and doctors may prefer a percutaneous treatment approach, which is associated with better upfront results, fewer complications, and quicker recovery,” Stone confirmed.
LMCAD occurs when the primary artery supplying oxygen-rich blood to most of the heart muscle is blocked by athersclerotic plaque, and about two-thirds of LMCAD cases are also accompanied by mild to moderate disease in the rest of the coronary arteries. For years, the standard treatment for all cases of LMCAD has been CABG surgery.
“Many patients with left main coronary artery disease who prefer a minimally invasive approach can now rest assured that a stent is as effective as bypass surgery for at least 3 years, and is initially safer, with fewer complications from the procedure," Stone said.
Source: Columbia University Medical Center
, JACC Cardiovascular Interventions