ESC and EACTS to review left main coronary artery stenosis evidence

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The European Society of Cardiology (ESC) and the European Association for Cardiothoracic Surgery (EACTS) have agreed to review available evidence for the treatment of patients with left main coronary artery stenosis. The organisations said in a joint statement today that they would review up-to-date evidence on the issue “when it is available”.

The review will include joint guidelines published by the two organisations in 2018 covering recommendations for the treatment of patients with left main coronary artery disease and stable angina.

In their joint statement, ESC and EACTS said that the review would take into account longer term outcome data from the trials of coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI), and added that an independent patient-level meta-analysis of these trials is currently under way. “The two organisations will establish a robust and transparent process to review this new evidence,” the statement adds.

EACTS withdrew its support for the 2018 guidelines, after a BBC investigation cast doubt on the findings of the EXCEL clinical trial, which was among the evidence used to inform the drafting of the guidelines. Among the questions over the EXCEL findings was the application of the definition of myocardial infarction (MI) used in the trial, after it was claimed that the parameters for MI set out in the trial directly influenced the outcomes. 

A paper published last week in the Journal of the American College of Cardiology (JACC) analysed the rates and clinical implications of alternative definitions of procedural myocardial infarction (PMI) used in the EXCEL trial, and led the trial investigators to conclude that while relative rates of PMI after PCI and coronary artery bypass grafting CABG vary according to definition, the protocol definition of PMI used in EXCEL is justified.

Further research has been published this week, also in JACC, looking at the optimal revascularisation strategy for patients with left main coronary artery disease. The paper by Sangwoo Park (Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea) evaluated outcomes from 3,488 patients from the IRIS-MAIN (Interventional Research Incorporation Society-Left MAIN Revascularization) registry, concluding that PCI was associated with an inferior primary composite outcome of death, MI, or stroke compared with CABG in patients with moderate or severe left ventricular dysfunction.

In the meantime, ESC and EACTS have recommended that treatment decisions for individual patients take into account all available published information. “As stated in the ESC/EACTS Guidelines on Myocardial Revascularization, a discussion within the heart team and with the patient should be the basis of all treatment decisions,” the statement concludes.


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