Prevalence of Left main coronary artery disease with diabetes and hypertension in STEMI patients

Aim: To determine the association of left main stem disease with diabetes and hypertension in STEMI patients underwent coronary angiography Methodology: This study was conducted at Department of Cardiology, Sheikh Zayed Hospital, Lahore during January to June 2019 where 220 patients with age ranging from 40-70 years whether male or female, presenting with STEMI, In Exposed Group: Patients presenting with STEMI having diabetes and hypertension and Unexposed Group: Patients of STEMI without diabetes and hypertension. We excluded all cases with recurrent MI or undergoing recurrent PCI (on medical record), valvular heart disease, and cardiogenic shock. Then two groups were formed i.e. exposed group with diabetes and hypertension and unexposed group without diabetes and hypertension. All patients underwent angiography by a senior consultant cardiologist with assistance of researcher. On angiography, presence of LMS disease was ≥50% occlusion (stenosis) in LMS artery. Angiography reports were assessed and LMS disease was noted labeled. Patients with LMS disease was managed as per hospital protocol. Results: In this study risk of LMS was higher among exposed group as compared to un exposed group. i.e. exposed: 19.1% & Unexposed: 5.5%, RR=3.50 The risk of LMS among exposed group was higher for patients in the age group 51-60 years (RR=8.00), for male patients (RR=5.76) risk for LMS was higher as compared to female patients in exposed group, patients with normal BMI (RR:2.20) and patients with shorter duration of STEMI in exposed group had higher risk for LMS (1-4 weeks: RR=7.54). Conclusion: Results of this study showed that hypertensive and diabetic patients presenting with STEMI had higher risk for LMS disease. Keywords: Left main stem, Diabetes, Hypertension, Coronary, Angiography

LEFT MAIN STEM DISEASE ON CORONARY ANGIOGRAPHY IN PATIENTS WITH NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

Objectives: The purpose of our study was to determine the frequency of left main stem disease on coronary angiography in patients with non-ST segment elevation myocardial infarction (NSTEMI). By studying the exact frequency of the left main stem (LMS) disease in NSTEMI patients in our population, we will be able to better risk stratify and plan further management for this group of patients. Methodology: This cross-sectional study was conducted at the Department of Cardiology, Chaudhry Pervez Elahi Institute of Cardiology (CPEIC), Multan from 14-June-2017 to 13-Dec-2017. Total 248 patients with NSTEMI were included in the study. Coronary angiography was done in all selected patients. Diagnosis of LMS disease was made when stenosis in the LMS artery was more than half of the diameter of the left main coronary artery. Results: There were 80.6% male and 19.4% female patients with a mean age 49.39±7.23 years. In this study, 37.1% patients were found with left main stem disease. Among LMS disease patients, there was 82.6% male and 17.4% female patients. 55.4% of patients were aged 50 years and above. 40.2% were smokers and 33.7% were diabetic. No significant association of LMS was found with the age group (p=0.66), gender (p=0.54), smoking status (p=0.54) and diabetes mellitus (p=0.95). Conclusion: In this study, we found a high frequency of LMS disease in our population. This subset of patients with NSTEMI requires early re-vascularization. This also signifies a need to re-evaluate our screening programs and management protocols related to coronary artery disease.

The EXCEL Trial: The Surgeons’ Perspective

There have been several investigations comparing the efficacy of percutaneous coronary intervention and coronary artery bypass grafting surgery for treatment of left main stem disease. This includes the Evaluation of XIENCE versus Coronary Artery Bypass Graft Surgery for Effectiveness of Left Main Revascularizaton (EXCEL) trial, which has garnered significant controversy surrounding its experimental design and reporting of its results. The authors review the methodology, results, caveats and statements on the EXCEL trial. They also review the other trials in the management of left main stem disease comparing percutaneous coronary intervention with coronary artery bypass grafting, as well as the SYNTAX score and its role in future guidelines for revascularisation. These findings have significant implications for current practice, influencing the growing role for multidisciplinary team meeting and allowing clinicians and patients to make the right choice.

Revascularisation of left main stem disease: a prospective analysis of modern practice and outcomes in a non-surgical centre

PurposeIn this study, we sought to prospectively analyse the management and long term outcomes associated with revascularisation of left main stem disease via percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in our centre.MethodsThis prospective study enrolled all patients with unprotected left main stem disease undergoing revascularisation from January 2013 to June 2014. Baseline characteristics, hospital presentation and hospital stay length were collected. Patients were followed up at 1, 2 and 3 years. Primary outcomes of Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) were defined as death, Q wave myocardial infarction, stroke, repeat revascularisation and readmission within 30 days.Results56 patients with significant left main stem coronary artery disease were identified from the clinical registry. 27 patients underwent PCI (median age 67.7) and 29 CABG (median age 68.6). PCI patients had a higher surgical risk as measured by mean euroSCORE (4.95±5.8 vs 3.11±3.85). At 3 years, total MACCE occurred in 29.6% of the PCI cohort and 27.5% of the CABG cohort. Death occurred in three patients in the PCI group within the first 6 months. Death occurred in one patient in the CABG group over 2 years postprocedure. Two patients in the CABG cohort presented with Transient Ischemic Attacks (TIAs) at 2-year follow-up. At 3 years, revascularisation occurred in three patients in the PCI cohort. There were no revascularisation events in the CABG cohort.ConclusionsPCI with modern drug eluting stents is a reasonable treatment option for unprotected left main stem disease in a non surgical centre.