1. Institute of Cardiology
G. Montalescot
Institute of Cardiology
Paris - France
Unprotected Left Main Revascularization
in Patients With Acute Coronary Syndromes
G Montalescot, D Brieger, KA Eagle, FA Anderson, G FitzGerald, MS Lee, PG Steg, A Avezum, SG Goodman, JM Gore for the GRACE Investigators

2. Background
Limited information on revascularization for unprotected left main coronary disease (ULMCD) :
 a few randomized studies performed in stable patients
 a limited number of small observational studies
We explored the treatment strategies applied to ULMCD in:
Unstable patients (ACS)
Emergency (e.g. STEMI)
Serious cases (e.g. shock, cardiac arrest)
GRACE registry: Data from 106 hospitals in 14 countries in North and South America, Europe, Australia, and New Zealand, between 2000 and 2007 (
in patients with ULMCD are limited to the Left Main Stenting trial and the LM subset of the SYNTAX trial

3. Study Flow Diagram ACS + LM stenosis (n=2783) PCI (n=514)
Analysis based on 43 018 patients
ACS +
LM stenosis
(n=2783)
Excluded:
Hx of CABG (n=921)
Both CABG + PCI during hospital° (n=43)
Missing data (n=20)
Study group: ACS +unprotected LM
(n=1799)
PCI
(n=514)
CABG
(n=612)
Conservative treatment (n=673)

4. ULMCD Revascularization in ACS
Temporal Trends in Severity of ACS
Temporal Trends in Type of Revascularization

5. In-Hospital Mortality
Cardiac arrest or cardiogenic shock
STEMI
ALL
34 %
11 %
7.7 %
14% at 6 months

6. Cumulative Death Rate by Revascularization Group as a Time-Varying Covariate
CABG
Conservative
PCI 45 90
135
180
0.20
0.10
Cumulative all death rate
Days since admission

7. Cox Regression Model for Death
Hospital stay
 early hazard of revascularization
PCI vs. Conservative: HR 2.60 (95% CI )
CABG vs. Conservative: HR 1.26 (95% CI )
From Discharge to 6 months
 improved survival of revascularization
so that if a patient underwent CABG on day 4 after admission they were counted as not having revascularization performed on days 0 to 3, and as having had CABG surgery from day 4 onwards.
PCI vs. Conservative: HR 0.45 (95% CI )
CABG vs. Conservative: HR 0.11 (95% CI )

8. Cumulative Rate of Stroke by Revascularization Group as a Time-Varying Covariate45 90
135
180
Days since admission
Cumulative all stroke rate
CABG
Conservative
PCI
0.08
0.04

9. Conclusion ULMCD in ACS is a rare situation (4%)
ULMCD in ACS is a serious situation (in-hospital mortality of 7.7%)
PCI has become the most common strategy of revascularization (is preferred in emergent/serious cases)
CABG is associated with good survival (is performed in lower-risk patients)
The 2 modes of revascularization appear complementary
No aspirin?
Would a bleeding occur, how would you manage?

10. Available now online from European Heart Journal
Authors: Gilles Montalescot, David Brieger, Kim A. Eagle, Frederick A. Anderson Jr, Gordon FitzGerald, Michael S. Lee, Ph Gabriel Steg, A´ lvaro Avezum, Shaun G. Goodman, and Joel M. Gore for the GRACE Investigators