Location of Coronary Artery Lesion Not Tied to Stenting Outcome

By David Douglas

March 25, 2020

NEW YORK (Reuters Health) - The outcomes of percutaneous coronary intervention (PCI) with new-generation drug-eluting stents (DES) in patients with proximal left anterior descending (P-LAD) coronary-artery lesions appear similar to those seen in patients with lesions in other segments, according to data from three clinical trials.

In revascularization guidelines, P-LAD coronary-artery stenosis is discussed separately, "mainly because of a higher adverse event risk and benefits of bypass surgery," Dr. Clemens von Birgelen of the University of Twente, in Enschede, the Netherlands, and colleagues write in JACC: Cardiovascular Interventions.

However, "Most of our knowledge about the optimal treatment of patients with P-LAD lesions is based on studies published years ago," they add, noting that to date, no randomized trial with contemporary coronary DES has addressed this issue.

Moreover, "The use of new-generation DES has been associated with lower event rates, but reliable clinical data on the use of these DES for treating patients with P-LAD lesions is scarce."

To investigate, the researchers studied data from three randomized trials on more than 6,000 patients with stable angina or various acute coronary syndromes who were treated with thin-strut new-generation DES.

About a quarter had at least one DES implanted in P-LAD, and 73.4% were exclusively treated in non-P-LAD segments. At baseline the P-LAD patients had more multi-vessel treatment and longer total stent length.

Follow-up at two years in nearly 6,000 patients showed that the composite endpoint of cardiac death, target-vessel myocardial infarction, or target-lesion revascularization was significantly higher in the P-LAD patients (7.6% vs. 6.0%).

This, say the researchers, was driven by a difference in target-vessel MI (4.1% vs. 2.6%), reflecting a difference in peri-procedural MI (3.2% vs. 1.8%). But there was no between-group difference in several other individual endpoints.

The rate of any repeat revascularization was significantly lower in P-LAD patients (5.8% vs. 7.5%), and multivariate analysis showed no independent association between stenting P-LAD lesions and clinical endpoints.

"These results imply that separate consideration in future revascularization guidelines may not be mandatory any longer," the researchers conclude.

Dr, Eric R. Bates, professor of internal medicine at the University of Michigan Health System, in Ann Arbor, is not convinced.

"A post hoc analysis of stent trials can only be considered hypothesis generating about this question and has no bearing on prospective clinical decision-making that has to evaluate medical therapy vs. PCI vs. CABG," he told Reuters Health by email.

"The follow-up," he added, "is too short to answer the question. I doubt that this publication would influence clinical-practice guideline committees."

Dr. Sorin J. Brener of New York-Presbyterian Brooklyn Methodist Hospital, who wrote an accompanying editorial, also has reservations.

"The results are encouraging, but the higher rate of target-lesion failure in this subset should alert us to the possibility that neither the length of follow-up nor the precision of the models is sufficient to alleviate the inherent concern regarding treatment of patients with these strategically located lesions," he told Reuters Health by email.

Dr. von Birgelen did not respond to requests for comment.

SOURCE: https://bit.ly/2weOkUq and https://bit.ly/2U68o4l JACC: Cardiovascular Interventions, online March 11, 2020.

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