Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry.

Abstract

Left main coronary artery disease (i.e., .50% stenosis) was found in 1,477 of 20,137 patients in the Coronary Artery Surgery Study (CASS) registry. Of these patients, 53 (3.6%) were asymptomatic. Asymptomatic and symptomatic patients were similar in regard to 1) severity of left main coronary artery stenosis (67% vs. 70%), 2) extent of proximal coronary artery disease (no differences in number of or severity of proximal stenoses), 3) left ventricular end-diastolic pressure (13 mm Hg vs. 14 mm Hg), 4) left ventricular wall motion score (9.1 vs. 8.7), and 5) number of coronary artery segments with greater than 70% stenosis (4.4 vs. 4.8). Among the asymptomatic patients, 47% received medical and 49% received surgical treatment. In the symptomatic group, 20% received medical and 78% received surgical therapy. The survival rate 5 years after surgery for treatment of left main coronary artery stenosis was 84% for the symptomatic patients and 88% for the asymptomatic patients (p=NS). Medical management of left main coronary artery disease produced a 5-year survival rate of 57% for asymptomatic patients and 58% for symptomatic patients. Within the asymptomatic subgroup, 88% of those surgically treated survived 5 years, whereas only 57% of those medically treated survived 5 years (p=0.02). Thus, for CASS patients with left main coronary artery disease, the percentage of those that were asymptomatic is low (3.6%); asymptomatic and symptomatic patients with left main coronary artery disease had no significant difference in severity of left main coronary artery stenosis, extent of overall coronary artery disease, or left ventricular function. Finally, in this nonrandomized series, survival in patients with asymptomatic left main coronary artery disease was significantly improved with surgery compared with medical management. (Circulation 1989;79:1171-1179 S everal randomized and observational studies show that the surgical treatment of symptomatic left main coronary artery disease improves survival significantly compared with medical management.1 17 Given the grim prognosis that left main disease has traditionally implied, these findings were not unexpected. However, close analysis of populations of patients with left main coronary artery disease suggests that the prognosis of From the Division of Cardiology

2013 Esc Guidelines on the Management of Stable Coronary Artery Disease

“…Преимущества КШ в улучшении выживаемости у пациентов со стенозом ствола ЛКА ≥50% были уста-новлены на основании выявления впечатляющих различий в исследовании Veterans Administration Cooperative Study в подгруппе из 113 пациентов [466,467] и подтверждены при последующем мета-анализе [468], а также при анализах данных из регистра CASS [469,470]. Сейчас эти данные нуждаются в повторной интерпретации, в свете появившихся более новых доказательств по оценке функциональной тяжести стенозов ствола ЛКА и возможности того, что ревас-куляризация может быть безопасно отложена при ФРК >0,80 [401].…”

ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina—Summary Article

“…In the Coronary Artery Surgery Study Registry, 60 asymptomatic patients with left main CAD who underwent coronary artery bypass grafting had a better outcome than those patients treated with medical therapy, but this was not a randomized trial. The most compelling randomized trial data on asymptomatic patients comes from the previously mentioned Asymptomatic Cardiac Ischemia Pilot (ACIP) study.…”

Trans Ulnar Approach for Unprotected Left Main Coronary Artery Disease

“…Significant unprotected left main coronary artery (ULMCA) disease occurs in 5-7% of patients undergoing coronary angiography [1,2] and patients with ULMCA disease treated medically have a three years mortality rate of 50% [3,4]. Advances in percutaneous intervention techniques and stent technology have allowed evolution of the role of percutaneous coronary intervention (PCI) for left main disease.…”