Global Risk Score for Best Revascularization Strategy
Background. Coronary artery bypass graft (CABG) is recommended for patients with unprotected left main stenosis (ULMS). Percutaneous coronary intervention (PCI) is only recommended in specific anatomic conditions as in patients with low/mid SYNTAX score (SS). The aim of this study was to assess if the clinical and anatomic global risk classification (GRC) can enhance the indication of both revascularization therapies.
Methods. A total of 407 patients with ULMS treated with CABG (n = 285) or PCI (n = 122) were prospectively collected. The decision to treat with CABG or PCI was dependent on patient and physician's choice. Patients with ST-elevation myocardial infarction, shock, or valve disease were excluded. Clinical follow-up was obtained at 3 years.
Results. Patients with low GRC (n = 151) treated with CABG vs those with PCI had similar cardiac mortality (5.9% vs 0%, respectively; P=.17) and major adverse cardiac events (MACE; 18.5% vs 12.5%, respectively; P=.40). Patients classified as mid GRC (n = 175) had similar cardiac death (11.1% vs 10.3%; P=.85) and MACE rates (20.7% vs 22.4%; P=.92) with CABG or PCI, respectively. Patients with high GRC (n = 81) treated with CABG had numerically fewer cardiac deaths (16.3% vs 28.1%; P=.16) and lower MACE rates (24.5% vs 40.6%; P=.048) than with PCI. Statistical models using the GRC as a predictor of cardiac death showed better goodness-of-fit than the SS.
Conclusion. Patients with low/mid GRC have similar mid-term outcomes with either CABG or PCI; patients with high GRC seem to benefit from CABG. Although further investigations are required, GRC is a better predictor of outcomes than SS.
Unprotected left main stenosis (ULMS) has been classically associated with unfavorable clinical outcomes when not revascularized. Coronary artery bypass graft (CABG) has been shown to significantly reduce rates of major adverse cardiac event (MACE) rates compared to medical treatment; today, CABG is still the standard of care for patients with ULM stenosis.
Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) has become an alternative revascularization therapy in selected patients with ULMS suitable for both revascularization therapies. Current guidelines only use anatomical criteria in order to determine which patients benefit the most from each revascularization modality. These criteria include: isolated ULMS, ULMS plus single- or double-vessel disease, or low-mid SYNTAX score (<33). However, none of these criteria take into account the patient's clinical condition.
The global risk classification (GRC) is a novel score system combining the clinical surgical additive EuroSCORE with the angiographic SYNTAX score (Table 1 shows the GRC algorithm). Recent publications suggest that the GRC is better able to discriminate and predict outcomes in patients with ULMS undergoing either CABG or PCI. Nevertheless, the ability of this score system to predict outcomes has only been tested in two different populations and there are few data suggesting that the GRC can predict what type of revascularization therapy is best in those patients.
The aims of this study are: (1) to assess the clinical outcomes of patients undergoing ULMS revascularization either with CABG or PCI according to the GRC; and (2) to assess the accuracy of the GRC to predict outcomes in patients undergoing CABG and PCI for ULMS.
Abstract and Introduction
Abstract
Background. Coronary artery bypass graft (CABG) is recommended for patients with unprotected left main stenosis (ULMS). Percutaneous coronary intervention (PCI) is only recommended in specific anatomic conditions as in patients with low/mid SYNTAX score (SS). The aim of this study was to assess if the clinical and anatomic global risk classification (GRC) can enhance the indication of both revascularization therapies.
Methods. A total of 407 patients with ULMS treated with CABG (n = 285) or PCI (n = 122) were prospectively collected. The decision to treat with CABG or PCI was dependent on patient and physician's choice. Patients with ST-elevation myocardial infarction, shock, or valve disease were excluded. Clinical follow-up was obtained at 3 years.
Results. Patients with low GRC (n = 151) treated with CABG vs those with PCI had similar cardiac mortality (5.9% vs 0%, respectively; P=.17) and major adverse cardiac events (MACE; 18.5% vs 12.5%, respectively; P=.40). Patients classified as mid GRC (n = 175) had similar cardiac death (11.1% vs 10.3%; P=.85) and MACE rates (20.7% vs 22.4%; P=.92) with CABG or PCI, respectively. Patients with high GRC (n = 81) treated with CABG had numerically fewer cardiac deaths (16.3% vs 28.1%; P=.16) and lower MACE rates (24.5% vs 40.6%; P=.048) than with PCI. Statistical models using the GRC as a predictor of cardiac death showed better goodness-of-fit than the SS.
Conclusion. Patients with low/mid GRC have similar mid-term outcomes with either CABG or PCI; patients with high GRC seem to benefit from CABG. Although further investigations are required, GRC is a better predictor of outcomes than SS.
Introduction
Unprotected left main stenosis (ULMS) has been classically associated with unfavorable clinical outcomes when not revascularized. Coronary artery bypass graft (CABG) has been shown to significantly reduce rates of major adverse cardiac event (MACE) rates compared to medical treatment; today, CABG is still the standard of care for patients with ULM stenosis.
Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) has become an alternative revascularization therapy in selected patients with ULMS suitable for both revascularization therapies. Current guidelines only use anatomical criteria in order to determine which patients benefit the most from each revascularization modality. These criteria include: isolated ULMS, ULMS plus single- or double-vessel disease, or low-mid SYNTAX score (<33). However, none of these criteria take into account the patient's clinical condition.
The global risk classification (GRC) is a novel score system combining the clinical surgical additive EuroSCORE with the angiographic SYNTAX score (Table 1 shows the GRC algorithm). Recent publications suggest that the GRC is better able to discriminate and predict outcomes in patients with ULMS undergoing either CABG or PCI. Nevertheless, the ability of this score system to predict outcomes has only been tested in two different populations and there are few data suggesting that the GRC can predict what type of revascularization therapy is best in those patients.
The aims of this study are: (1) to assess the clinical outcomes of patients undergoing ULMS revascularization either with CABG or PCI according to the GRC; and (2) to assess the accuracy of the GRC to predict outcomes in patients undergoing CABG and PCI for ULMS.