Author + information
- Received May 31, 2018
- Revision received August 13, 2018
- Accepted September 4, 2018
- Published online December 17, 2018.
- Jamie Diamond, MD, MPHa,
- Mahesh V. Madhavan, MDa,
- Joseph F. Sabik III, MDb,
- Patrick W. Serruys, MD, PhDc,
- Arie Pieter Kappetein, MD, PhDd,
- Martin B. Leon, MDa,e,
- David P. Taggart, MD, PhDf,
- Jacques Berland, MDg,
- Marie-Claude Morice, MDh,
- Bernard J. Gersh, MB, ChB, DPhili,
- David E. Kandzari, MDj,
- Ovidiu Dressler, MDe and
- Gregg W. Stone, MDa,e,∗ ()
- aNewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
- bDepartment of Surgery, UH Cleveland Medical Center, Cleveland, Ohio
- cImperial College of Science, Technology and Medicine, London, United Kingdom
- dDepartment of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
- eClinical Trials Center, Cardiovascular Research Foundation, New York, New York
- fJohn Radcliffe Hospital, Oxford, United Kingdom
- gClinique Saint Hilaire, Rouen, France
- hRamsay Générale de Santé – Institut Cardiovasculaire Paris Sud, Massy, France
- iMayo Clinic College of Medicine, Rochester, Minnesota
- jPiedmont Heart Institute, Atlanta, Georgia
- ↵∗Address for correspondence:
Dr. Gregg W. Stone, Columbia University Medical Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, New York 10019.
Objectives The aim of this study was to determine whether high-risk patients with left main coronary artery disease (LMCAD) and prior cerebrovascular disease (CEVD) preferentially benefit from revascularization by percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG).
Background Patients with known CEVD requiring revascularization are often referred to PCI rather than CABG. There is a paucity of data regarding the impact of CEVD in patients with LMCAD undergoing revascularization.
Methods In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with LMCAD and low or intermediate SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) scores were randomized to PCI with everolimus-eluting stents versus CABG. The effects of prior CEVD, defined as prior stroke, transient ischemic attack, or carotid artery disease, on 30-day and 3-year event rates were assessed.
Results Prior CEVD was present in 233 of 1,898 patients (12.3%). These patients were older and had higher rates of comorbidities, including hypertension, diabetes, peripheral vascular disease, anemia, chronic kidney disease, and prior PCI, compared with those without prior CEVD. Patients with prior CEVD had higher rates of stroke at 30 days (2.2% vs. 0.8%; p = 0.05) and 3 years (6.4% vs. 2.2%; p = 0.0003) and higher 3-year rates of the primary endpoint of all-cause death, stroke, or myocardial infarction (25.0% vs. 13.6%; p < 0.0001). The relative effects of PCI versus CABG on the 30-day and 3-year rates of stroke (pinteraction = 0.65 and 0.16, respectively) and the 3-year rates of the primary composite endpoint (pinteraction = 0.14) were consistent in patients with and those without prior CEVD.
Conclusions Patients with LMCAD and prior CEVD compared with those without CEVD have higher rates of stroke and reduced event-free survival after revascularization. Data from the EXCEL trial do not a priori support a preferential role of PCI over CABG in patients with known CEVD.
- cerebrovascular disease
- coronary artery bypass graft surgery
- coronary artery disease
- left main disease
- percutaneous coronary intervention
Dr. Madhavan has received a research grant from the American Medical Association Foundation. Dr. Sabik is a consultant for Medtronic, Edwards Lifesciences, and Sorin; and an advisory board member for Medtronic Cardiac Surgery. Dr. Serruys is a consultant for Abbott, Biosensors, Medtronic, Micell Technologies, QualiMed, SINOMED, St. Jude Medical, Stentys, Svelte, Philips/Volcano, and Xeltis. Dr. Kappetein is an employee of Medtronic. Dr. Berland has received research grants from Terumo, Abbott, Biosensors, and Celonova. Dr. Gersh is a consultant for Boston Scientific and Medtronic. Dr. Kandzari has received consulting fees from Medtronic and Boston Scientific; and has received research support from Medtronic, Abbott Vascular, Boston Scientific, Biotronik, and Medinol. Dr. Stone’s employer, Columbia University, receives royalties for sale of the MitraClip. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 31, 2018.
- Revision received August 13, 2018.
- Accepted September 4, 2018.
- 2018 American College of Cardiology Foundation
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