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dc.contributor.authorMontalescot, Gilles
dc.contributor.authorBrieger, David
dc.contributor.authorEagle, Kim A.
dc.contributor.authorAnderson, Frederick A. Jr.
dc.contributor.authorFitzgerald, Gordon
dc.contributor.authorLee, Michael S.
dc.contributor.authorSteg, Phillippe Gabriel
dc.contributor.authorAvezum, Alvaro
dc.contributor.authorGoodman, Shaun G.
dc.contributor.authorGore, Joel M.
dc.date2022-08-11T08:08:08.000
dc.date.accessioned2022-08-23T15:43:56Z
dc.date.available2022-08-23T15:43:56Z
dc.date.issued2009-09-02
dc.date.submitted2011-09-23
dc.identifier.citation<p>Eur Heart J. 2009 Oct;30(19):2308-17. Epub 2009 Aug 30. <a href="http://dx.doi.org/10.1093/eurheartj/ehp353">Link to article on publisher's site</a></p>
dc.identifier.issn0195-668X (Linking)
dc.identifier.doi10.1093/eurheartj/ehp353
dc.identifier.pmid19720640
dc.identifier.urihttp://hdl.handle.net/20.500.14038/27206
dc.description.abstractAIMS: In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary disease (ULMCD) has been little studied. The objectives of the present study were to describe the practice of ULMCD revascularization in ACS patients and its evolution over an 8-year period, analyse the prognosis of this population and determine the effect of revascularization on outcome. METHODS AND RESULTS: Of 43 018 patients enrolled in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007, 1799 had significant ULMCD and underwent percutaneous coronary intervention (PCI) alone (n = 514), coronary artery bypass graft (CABG) alone (n = 612), or no revascularization (n = 673). Mortality was 7.7% in hospital and 14% at 6 months. Over the 8-year study, the GRACE risk score remained constant, but there was a steady shift to more PCI than CABG over time. Patients undergoing PCI presented more frequently with ST-segment elevation myocardial infarction (STEMI), after cardiac arrest, or in cardiogenic shock; 48% of PCI patients underwent revascularization on the day of admission vs. 5.1% in the CABG group. After adjustment, revascularization was associated with an early hazard of hospital death vs. no revascularization, significant for PCI (hazard ratio (HR) 2.60, 95% confidence interval (CI) 1.62-4.18) but not for CABG (1.26, 0.72-2.22). From discharge to 6 months, both PCI (HR 0.45, 95% CI 0.23-0.85) and CABG (0.11, 0.04-0.28) were significantly associated with improved survival in comparison with an initial strategy of no revascularization. Coronary artery bypass graft revascularization was associated with a five-fold increase in stroke compared with the other two groups. CONCLUSION: Unprotected left main coronary disease in ACS is associated with high mortality, especially in patients with STEMI and/or haemodynamic or arrhythmic instability. Percutaneous coronary intervention is now the most common revascularization strategy and preferred in higher risk patients. Coronary artery bypass graft is often delayed and performed in lower risk patients, leading to good 6-month survival. The two approaches therefore appear complementary.
dc.language.isoen_US
dc.relation<p><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&list_uids=19720640&dopt=Abstract">Link to Article in PubMed</a></p>
dc.relation.urlhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2755115
dc.subjectAcute Coronary Syndrome
dc.subjectAged
dc.subjectAngioplasty, Balloon, Coronary
dc.subjectCoronary Artery Bypass
dc.subjectFemale
dc.subjectHumans
dc.subjectMale
dc.subjectMiddle Aged
dc.subjectMyocardial Infarction
dc.subjectMyocardial Revascularization
dc.subjectRegistries
dc.subjectShock, Cardiogenic
dc.subject*Stents
dc.subjectStroke
dc.subjectLeft main disease
dc.subjectAcute coronary syndrome
dc.subjectCardiovascular Diseases
dc.subjectDiagnosis
dc.subjectHealth Services Research
dc.subjectPathological Conditions, Signs and Symptoms
dc.subjectSurgical Procedures, Operative
dc.subjectTherapeutics
dc.titleUnprotected left main revascularization in patients with acute coronary syndromes
dc.typeJournal Article
dc.source.journaltitleEuropean heart journal
dc.source.volume30
dc.source.issue19
dc.identifier.legacycoverpagehttps://escholarship.umassmed.edu/cor_grace/23
dc.identifier.contextkey2254942
html.description.abstract<p>AIMS: In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary disease (ULMCD) has been little studied. The objectives of the present study were to describe the practice of ULMCD revascularization in ACS patients and its evolution over an 8-year period, analyse the prognosis of this population and determine the effect of revascularization on outcome.</p> <p>METHODS AND RESULTS: Of 43 018 patients enrolled in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007, 1799 had significant ULMCD and underwent percutaneous coronary intervention (PCI) alone (n = 514), coronary artery bypass graft (CABG) alone (n = 612), or no revascularization (n = 673). Mortality was 7.7% in hospital and 14% at 6 months. Over the 8-year study, the GRACE risk score remained constant, but there was a steady shift to more PCI than CABG over time. Patients undergoing PCI presented more frequently with ST-segment elevation myocardial infarction (STEMI), after cardiac arrest, or in cardiogenic shock; 48% of PCI patients underwent revascularization on the day of admission vs. 5.1% in the CABG group. After adjustment, revascularization was associated with an early hazard of hospital death vs. no revascularization, significant for PCI (hazard ratio (HR) 2.60, 95% confidence interval (CI) 1.62-4.18) but not for CABG (1.26, 0.72-2.22). From discharge to 6 months, both PCI (HR 0.45, 95% CI 0.23-0.85) and CABG (0.11, 0.04-0.28) were significantly associated with improved survival in comparison with an initial strategy of no revascularization. Coronary artery bypass graft revascularization was associated with a five-fold increase in stroke compared with the other two groups.</p> <p>CONCLUSION: Unprotected left main coronary disease in ACS is associated with high mortality, especially in patients with STEMI and/or haemodynamic or arrhythmic instability. Percutaneous coronary intervention is now the most common revascularization strategy and preferred in higher risk patients. Coronary artery bypass graft is often delayed and performed in lower risk patients, leading to good 6-month survival. The two approaches therefore appear complementary.</p>
dc.identifier.submissionpathcor_grace/23
dc.contributor.departmentDepartment of Medicine, Division of Cardiovascular Medicine
dc.contributor.departmentCenter for Outcomes Research
dc.source.pages2308-17


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