GRACE Registry Shows PCI and CABG to Be Complementary in ULMCAD

September 1, 2009—At the European Society of Cardiology (ESC) Congress in Barcelona, Spain, the GRACE (Global Registry of Acute Coronary Events) registry analysis of a group of high-risk emergency department patients was presented and showed that percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery proved to be "complementary" strategies for patients with unprotected left main coronary artery disease (ULMCAD). The presentation showed that PCI is now used preferentially in higher-risk patients and is associated with frequent repeat revascularizations. The results also showed that CABG is performed preferentially in lower-risk patients and is associated with better survival but more frequent strokes.

According to the ESC, the registry represents one of the largest data sets ever for ULMCAD. The objective of this analysis was to describe the practice of ULMCAD revascularization in acute coronary syndrome (ACS) patients and follow its evolution for 8 years. GRACE is an observational study based on 43,018 patients presenting with ACS between 2000 and 2007 to 106 hospitals in 14 countries. From the database, 1,799 patients with ACS and unprotected left main stem were identified; of these, 514 had undergone PCI alone, 612 had undergone CABG alone, and 673 had undergone no revascularization procedures and only received medical treatment.

In presenting the data, Gilles Montalescot, MD, said that the GRACE results showed that overall in-hospital mortality for ULMCAD was 7.7%, but reached 11% in patients who presented with ST-elevated myocardial infarction or new left bundle branch block and was as high as 34% for patients with cardiogenic shock or cardiac arrest. The analysis explored the possibility of links between the type of revascularization and mortality and found that both PCI and CABG showed an early mortality hazard for revascularization.

"But when the analysis was repeated for the time period from discharge to 6 months, revascularization improved survival rate," commented Dr. Montalescot. "It is clear from this study that the two modes of revascularization are useful and probably complementary."

The ESC reported that the registry revealed that CABG revascularization was associated with a fivefold increase in stroke compared with the other two groups, a complication also identified in the SYNTAX study. The registry also revealed that over the past 8 years, the number of PCI procedures performed has shown a steady increase over CABG.

In 2000, the rate of CABG utilization was 2.5 times higher than the rate of PCI, but by 2007, the PCI rate was 40%, while CABG was 25%. "This reflects how clinicians are feeling more confident about tackling difficult cases with PCI," stated Dr. Montalescot.

The study was published in the European Heart Journal (2009;30:2308-2317). In an accompanying editorial, Roberto Corti, MD, and Stefan Toggweiler, MD, note that the study provides important new data, highlighting the importance of prompt and complete revascularization in patients presenting with ACS and ULMCAD.