Prognostic significance of severe narrowing of the proximal portion of the left anterior descending coronary artery

doi:10.1016/0002-9149(86)90238-9

The American Journal of Cardiology

Volume 58, Issue 1, 1 July 1986, Pages 42-46

https://doi.org/10.1016/0002-9149(86)90238-9 Get rights and content

Abstract

To determine the prognostic importance of significant narrowings involving the proximal left anterior descending coronary artery (LAD), 866 medically treated patients with significant coronary artery disease (CAD) were followed after cardiac catheterization for a mean of 17 months (range 1 to 46). Coronary narrowings in all patients were evaluated based on site relative to large branches and on angiographic severity. Prognosis was best predicted by the presence of at least 70% diameter reductions in the LAD before the first 2 large branches (χ₂ = 16, p = 0.0001). At 3 years, there was a 94% cumulative survival rate in patients with less than 70% stenoses at this location, but an 82% survival rate in patients with 70% or more stenoses (p < 0.0001). In addition, although the presence of proximal LAD narrowings was the best predictor of prognosis in patients with a low global ejection fraction, this was not so in patients with normal ejection fractions, as this subgroup had an excellent overall prognosis. Thus, the presence and severity of significant stenoses in the proximal LAD are stronger predictors of prognosis than stenoses elsewhere in the major coronary arteries. The presence of an angiographically significant narrowing in this anatomic location is highly correlated with an increased 1- to 3-year mortality rate.

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Efficacy and safety of one-month DAPT followed by 23-month ticagrelor monotherapy in patients undergoing proximal LAD stenting: Insights from the GLOBAL LEADERS trial
2020, International Journal of Cardiology
Citation Excerpt :
Traditionally, several lesion subsets, such as lesions in the left main coronary artery, the proximal LAD, and multivessel disease have historically been referred for CABG rather than PCI. The proximal LAD in particular is regarded as a high-risk segment for adverse outcomes [2,3] in light of the large territory of left ventricular myocardium it subtends. Historically, PCI of the proximal LAD using bare metal stents and first-generation DES had a significantly higher risk of repeat revascularization compared with CABG, while the risk of mortality and MI was similar [27].
Data on optimal antiplatelet therapy in patients undergoing stenting of the proximal left anterior descending artery (LAD) are limited.
This is a post-hoc analysis of the GLOBAL LEADERS trial, a prospective, multi-center, randomized controlled trial, comparing the experimental strategy (1-month dual anti-platelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) with the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy) in relation to stenting of the proximal LAD. The primary endpoint was the composite of all-cause death or new Q-wave myocardial infarction (MI) and key secondary safety endpoint was Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding at two years.
Among 15,845 patients included in the analysis, 3823 (23.9%) patients underwent stenting of the proximal LAD, while 12,022 (75.2%) did not. In the proximal LAD stenting group, there was no significant difference in the risk of the primary endpoint between the two antiplatelet strategies (3.38% vs. 3.93%; hazard ratio [HR]:0.86; 95% CI:0.62–1.20; P_interaction = 0.951). However, the risk of any MI (2.63% vs. 3.88%; HR:0.68; 95% CI:0.47–0.97; P_interaction = 0.015) and any revascularization (7.84% vs. 9.94%; HR:0.78; 95% CI:0.63–0.97; P_interaction = 0.058) was significantly lower in the experimental strategy group, while demonstrating a similar risk of BARC type 3 or 5 bleeding between the two antiplatelet strategies (1.93% vs. 1.99%; HR:0.98; 95% CI:0.62–1.54; P_interaction = 0.981).
The present study showed patients having stenting to the proximal LAD could potentially benefit from the experimental strategy with lower ischaemic events without a trade-off in major bleeding at two years.
10-Year Survival After FFR-Guided Strategy in Isolated Proximal Left Anterior Descending Coronary Stenosis
2019, Journal of the American College of Cardiology
Impact of Chronic Total Coronary Occlusion Location on Long-term Survival After Percutaneous Coronary Intervention
2019, Revista Espanola de Cardiologia
Se dispone de poca información sobre los resultados clínicos del tratamiento médico óptimo (TMO) comparado con la revascularización mediante intervención coronaria percutánea (ICP) en pacientes con oclusión coronaria total (OCT) crónica de la arteria descendente anterior proximal o media (ADApm). Por lo tanto, el objetivo del presente estudio es comparar los resultados a largo plazo de los pacientes con OTC de la ADApm tratados con ICP o con TMO.
Entre marzo de 2003 y febrero de 2012, se reclutó a 2.024 pacientes con OCT en un registro unicéntrico. De este grupo se excluyó a los pacientes con OCT revascularizados quirúrgicamente, y finalmente resultaron 1.547 pacientes. Se los estratificó según la localización anatómica de la OCT (ADApm o no-ADApm) y la estrategia inicial de tratamiento (TMO o ICP). Se aplicó emparejamiento por puntuación de propensión. El objetivo primario fue la mortalidad cardiaca.
El seguimiento medio fue de 45,9 [intervalo intercuartílico, 22,9-71,1] meses. Tras el emparejamiento por puntuación de propensión, se observó una incidencia en la mortalidad cardiaca significativamente menor en el grupo de pacientes con OTC tratados con ICP sobre ADApm que en el de ADApm con TMO (HR = 0,54; IC95%, 0,31-0,94; p = 0,029). Sin embargo, no hubo diferencias significativas en la mortalidad cardiaca entre los grupos de ICP y de TMO de pacientes con OCT de no-ADApm (HR = 0,62; IC95%, 0,27-1,42; p = 0,26).
La estrategia incial de ICP sobre ADApm, pero no sobre no-ADApm, se asoció con una mejor supervivencia a largo plazo.
Limited data are available on the clinical outcomes of optimal medical therapy (OMT) compared with revascularization by percutaneous coronary intervention (PCI) in patients with chronic total coronary occlusion (CTO) of the proximal or middle left anterior descending artery (pmLAD). Therefore, the objective of this study was to compare the long-term outcomes of patients with pmLAD CTO who were treated with a PCI strategy with those of patients treated with an OMT strategy.
Between March 2003 and February 2012, 2024 patients with CTO were enrolled in a single-center registry. Among this patient group, we excluded CTO patients who underwent coronary artery bypass grafting. After the exclusion, a total of 1547 patients remained. They were stratified according to classification of coronary segments (pmLAD or non-pmLAD CTO) and the initial treatment strategy (OMT or PCI). Propensity score matching was performed. The primary outcome was cardiac death.
The median follow-up was 45.9 (interquartile range, 22.9-71.1) months. After propensity score matching, the incidence of cardiac death (HR, 0.54; 95%C, 0.31-0.94, P = .029) was significantly lower in the PCI with pmLAD CTO group than in the OMT group. In contrast, no significant difference was found in the rate of cardiac death between the PCI and OMT groups with non-pmLAD CTO (HR, 0.62; 95%CI, 0.27–1.42, P = .26).
As an initial treatment strategy, PCI of pmLAD CTO, but not PCI of non-pmLAD, is associated with improved long-term survival.
Full English text available from:www.revespcardiol.org/en
Comparison of Outcomes of Coronary Artery Bypass Grafting Using Internal Mammary Graft Versus Percutaneous Coronary Intervention for Isolated Proximal Left Anterior Descending Narrowing
2017, American Journal of Cardiology
There are limited contemporary studies comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for isolated proximal left anterior descending (LAD) disease. Increasing stent length and decreasing stent diameters are associated with increased risk of restenosis and adverse outcomes after PCI. Whether these parameters influence outcomes when comparing CABG and PCI is unclear. We compared CABG and PCI in 3,473 patients who underwent revascularization for isolated proximal LAD disease from 2004 to 2015 at Harefield Hospital, UK; 3,078 patients (89%) had PCI and 384 patients had CABG (11%). We analyzed all-cause mortality at 3 years. The unadjusted mortality rates were similar (PCI vs CABG: 9.5% vs 7.0%, p = 0.109). PCI was associated with comparable mortality (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.70 to 1.89, p = 0.593), even when stratified to bare-metal stents (HR 1.58, 95% CI 0.89 to 2.80, p = 0.121); first-generation drug-eluting stents (FDES; HR 1.16, 95% CI 0.67 to 2.02, p = 0.597); and second-generation DES (SDES; HR 0.98, 95% CI 0.53 to 1.82, p = 0.946). Stent diameters did not influence outcomes, but PCI was associated with higher mortality when stent length ≥30 mm (HR 2.12, 95% CI 1.12 to 4.03, p = 0.022). There was a linear association between stent length and mortality, and for every 1-mm increase in stent length, the 3-year mortality increased by 0.32%. In conclusion, for patients with isolated proximal LAD disease, PCI and CABG were associated with similar mortality. Increasing stent length was progressively associated with worse outcomes with PCI. For longer segments of disease requiring stent lengths ≥30 mm, CABG may be associated with better outcomes.
Comparison of sirolimus-eluting stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: 7-year follow-up of a randomized trial
2015, JACC: Cardiovascular Interventions
The aim of this analysis was to assess the 7-year long-term safety and effectiveness of a randomized comparison of percutaneous coronary intervention (PCI) with sirolimus-eluting stents (SES) versus minimally invasive direct coronary artery bypass (MIDCAB) surgery for the treatment of isolated proximal left anterior descending lesions.
Long-term follow-up data comparing PCI by SES and MIDCAB surgery for isolated proximal left anterior descending lesions are sparse.
Patients were randomized either to PCI with SES (n = 65) or MIDCAB (n = 65). Follow-up data were obtained after 7 years with respect to the primary composite endpoint of death, myocardial infarction, and target vessel revascularization. Angina was assessed by the Canadian Cardiovascular Society classification and quality of life with Short Form 36 and MacNew quality of life questionnaires.
Follow-up was conducted in 129 patients at a median time of 7.3 years (interquartile range: 5.7, 8.3). There were no significant differences in the incidence of the primary composite endpoint between groups (22% PCI vs. 12% MIDCAB; p = 0.17) or the endpoints death (14% vs. 17%; p = 0.81) and myocardial infarction (6% vs. 9%, p = 0.74). However, the target vessel revascularization rate was higher in the PCI group (20% vs. 1.5%; p < 0.001). Clinical symptoms and quality of life improved significantly from baseline with both interventions and were similar in magnitude between groups.
At 7-year follow-up, PCI by SES and MIDCAB in isolated proximal left anterior descending lesions yielded similar long-term outcomes regarding the primary composite clinical endpoint and quality of life. Target vessel revascularization was more frequent in the PCI group. (MIDCAB Versus DES in Proximal LAD Lesions; NCT00299429)
Revascularization strategy for proximal LAD disease: Left internal mammary to LAD artery still rules the roost
2014, Journal of the American College of Cardiology

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Prognostic significance of severe narrowing of the proximal portion of the left anterior descending coronary artery

Abstract

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol