Randomized Trial of Stents Versus Bypass Surgery for Left Main Coronary Artery Disease 5-Year Outcomes of the PRECOMBAT Study

AbstractBackgroundIn a previous randomized trial, we found that percutaneous coronary intervention (PCI) was not inferior to coronary artery bypass grafting (CABG) for the treatment of unprotected left main coronary artery stenosis at 1 year.ObjectivesThis study sought to determine the 5-year outcomes of PCI compared with CABG for the treatment of unprotected left main coronary artery stenosis.MethodsWe randomly assigned 600 patients with unprotected left main coronary artery stenosis to undergo PCI with a sirolimus-eluting stent (n = 300) or CABG (n = 300). The primary endpoint was a major adverse cardiac or cerebrovascular event (MACCE: a composite of death from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization) and compared on an intention-to-treat basis.ResultsAt 5 years, MACCE occurred in 52 patients in the PCI group and 42 patients in the CABG group (cumulative event rates of 17.5% and 14.3%, respectively; hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 0.84 to 1.90; p = 0.26). The 2 groups did not differ significantly in terms of death from any cause, myocardial infarction, or stroke as well as their composite (8.4% and 9.6%; HR, 0.89; 95% CI, 0.52 to 1.52; p = 0.66). Ischemia-driven target vessel revascularization occurred more frequently in the PCI group than in the CABG group (11.4% and 5.5%, respectively; HR: 2.11; 95% CI: 1.16 to 3.84; p = 0.012).ConclusionsDuring 5 years of follow-up, our study did not show significant difference regarding the rate of MACCE between patients who underwent PCI with a sirolimus-eluting stent and those who underwent CABG. However, considering the limited power of our study, our results should be interpreted with caution. (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT]; NCT00422968

Deep learning of ECG waveforms for diagnosis of heart failure with a reduced left ventricular ejection fraction

The performance and clinical implications of the deep learning aided algorithm using electrocardiogram of heart failure (HF) with reduced ejection fraction (DeepECG-HFrEF) were evaluated in patients with acute HF. The DeepECG-HFrEF algorithm was trained to identify left ventricular systolic dysfunction (LVSD), defined by an ejection fraction (EF) < 40%. Symptomatic HF patients admitted at Seoul National University Hospital between 2011 and 2014 were included. The performance of DeepECG-HFrEF was determined using the area under the receiver operating characteristic curve (AUC) values. The 5-year mortality according to DeepECG-HFrEF results was analyzed using the Kaplan-Meier method. A total of 690 patients contributing 18,449 ECGs were included with final 1291 ECGs eligible for the study (mean age 67.8 +/- 14.4 years; men, 56%). HFrEF (+) identified an EF < 40% and HFrEF (-) identified EF >= 40%. The AUC value was 0.844 for identifying HFrEF among patients with acute symptomatic HF. Those classified as HFrEF (+) showed lower survival rates than HFrEF (-) (log-rank p < 0.001). The DeepECG-HFrEF algorithm can discriminate HFrEF in a real-world HF cohort with acceptable performance. HFrEF (+) was associated with higher mortality rates. The DeepECG-HFrEF algorithm may help in identification of LVSD and of patients at risk of worse survival in resource-limited settings.N

Coronary Artery Bypass Grafting Versus Drug-Eluting Stents Implantation for Previous Myocardial Infarction

Patients with previous myocardial infarction (MI) have a high risk of recurrence. Little is known about the effectiveness of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in patients with a previous MI and left main or multivessel coronary artery disease (CAD). We compared long-term outcomes of these 2 strategies in 672 patients with previous MI and left main or multivessel CAD, who underwent CABG (n = 349) or PCI with DES (n = 323). A pooled database from the BEST, PRECOMBAT, and SYNTAX trials was analyzed, and the primary outcome was a composite of death from any causes, MI, or stroke. Baseline characteristics were similar between the 2 groups. The median follow-up duration was 59.8 months. The rate of the primary outcome was significantly lower with CABG than PCI (hazard ratio [HR] 0.59, 95% CI 0.42 to 0.82; p = 0.002). This difference was driven by a marked reduction in the rate of MI (HR 0.29, 95% CI 0.16 to 0.55, p <0.001). The benefit of CABG over PCI was consistent across all major subgroups. The individual risks of death from any causes or stroke were comparable between the 2 groups. Conversely, the rate of repeat revascularization was significantly lower with CABG than PCI (HR 0.34, 95% CI 0.22 to 0.51, p <0.001). In conclusion, in the patients with previous MI and left main or multivessel CAD, compared to PCI with DES, CABG significantly reduces the risk of death from any causes, MI, or strok