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2 Minute Medicine | October 24, 2014

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The PRECOMBAT trial: PCI vs. CABG in left main coronary artery stenosis [Classics Series]

| Andrew Cheung, MD
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1. For patients with left main coronary artery stenosis, angioplasty with sirolimus-eluting stents was noninferior to coronary artery bypass grafting with respect to subsequent cardiovascular or cerebrovascular events.

2. PCI patients experienced a significantly higher incidence of ischemia-driven target vessel revascularization compared to CABG patients.

3. Because of low event rates, the study was underpowered

Original Date of Publication: May 5, 2011

Study Rundown: The Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease (PRECOMBAT) trial compared percutaneous coronary intervention (PCI) to coronary artery bypass grafting (CABG) in patients with left main coronary artery stenosis. After being assigned to PCI with a sirolimus-eluting stent or CABG, patients were followed for 2 years after randomization. At 2 years post-intervention, PCI and CABG patients were found to have similar incidences of major coronary and cerebrovascular events, as well as similar cumulative incidence of death from any cause. PCI-treated patients were found to have a significantly higher incidence of ischemia-driven target vessel revascularization when compared with CABG patients (HR 2.18; 95%CI 1.10-4.32).

In summary, this study demonstrates that PCI was noninferior to CABG in treating left main coronary artery stenosis with regards to the primary composite endpoint (i.e., major adverse cardiac or cerebrovascular events). As a result of low event rates, however, the study was underpowered and the study authors have noted that these findings should not be clinically directive.

Please click to read study in NEJM

In-Depth [randomized, controlled study]: This trial was conducted at 13 medical centers across South Korea. Eligible patients were above the age of 18 and had received a diagnosis of stable angina, unstable angina, silent ischemia, or non–ST-elevation myocardial infarction (NSTEMI), with more than 50% stenosis of the left main coronary artery and eligible for CABG or PCI at their respective medical institution. Patient follow-up was standardized only within the first year, at 30 days, 6 months, 9 months, and 12 months after randomization. The primary endpoint was a composite of death from MI, stroke, or any other cause, as well as nonfatal MI, stroke, ischemia-driven target vessel revascularization, stent thrombosis, or symptomatic graft vessel occlusion. There were no significant differences between the two groups with regards to the primary endpoint (HR 1.50; 95%CI 0.90-2.52). Ischemia-driven target vessel revascularization (i.e., repeat revascularization when stenosis of 50% with ischemic signs/symptoms or 70% without ischemic signs/symptoms) was significantly higher in the PCI group (HR 2.18; 95%CI 1.10-4.32).

By Jay Rajan and Andrew Cheung, M.D.

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