In This Edition
Literature At A Glance
A guide to this month’s studies
- PCI Not Inferior to CABG in Left Main Coronary Artery Stenosis at One Year, But Requires Further Study
- CABG Did Not Decrease Mortality in Patients with CAD and Left Ventricular Dysfunction
- Linezolid Not Superior to Glycopeptide Antibiotics in Treatment of Nosocomial Pneumonia
- CRP and Procalcitonin Independently Differentiated Pneumonia from Asthma or COPD Exacerbation
- Survival Benefit Demonstrated with FOLFIRINOX in Select Patients with Metastatic Pancreatic Cancer
- MRSA Bundle Implementation at VA Hospitals Reduced Healthcare-Associated MRSA Infections
- New Left Bundle Branch Block Does Not Predict MI
- Acute Beta-Blocker Therapy for MI Increased Risk of Shock
PCI Not Inferior to CABG in Left Main Coronary Artery Stenosis at One Year, But Requires Further Study
Clinical question: Is percutaneous coronary intervention (PCI) an acceptable alternative to coronary artery bypass grafting (CABG) in unprotected left main coronary artery disease (CAD)?
Background: The current standard of care for unprotected left main CAD is CABG. A sub-study from a large randomized trial suggests that PCI might be an alternative to CABG for patients with left main CAD. Outcomes after the two treatments have not been directly compared in an appropriately powered trial.
Study design: Prospective, open-label, randomized trial powered for noninferiority.
Setting: Thirteen sites in South Korea.
Synopsis: Six hundred patients with newly diagnosed left main disease with >50% stenosis were randomized to PCI with a sirolimus-eluting stent versus CABG. The primary endpoint of major adverse cardiac or cerebrovascular events occurred in 8.7% in the PCI group and 6.7% in the CABG group at one year (absolute risk difference 2 percentage points, 95% CI, -1.6 to 5.6; P=0.01), which was considered noninferior.
However, ischemia-driven target-vessel revascularization occurred in significantly more patients in the PCI group than in the CABG group. The wide noninferiority margin was due to an unexpectedly low rate of events, thus underpowering the study. Also, study duration was only two years.
Bottom line: PCI with a sirolimus-eluting stent was noninferior to CABG for unprotected left main CAD in this study, but the wide noninferiority margin and limited follow-up duration limit clinical application.
Reference: Park SJ, Kim YH, Park DW, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011;364(18):1718-1727.
CABG Did Not Decrease Mortality in Patients with CAD and Left Ventricular Dysfunction
Clinical question: What role does coronary-artery bypass grafting (CABG) have in the treatment of patients with both coronary artery disease (CAD) and heart failure?
Background: Although CAD is the most common cause of heart failure, early trials that evaluated the use of CABG in relieving angina excluded patients who had left ventricular (LV) dysfunction with ejection fraction <35%. It is unknown whether CABG adds mortality benefit to intensive medical treatment in patients with CAD and LV dysfunction.
Study design: Multicenter, nonblinded, randomized trial.
Setting: One hundred twenty-seven sites in 26 countries.
Synopsis: From July 2002 to May 2007, 1,212 patients with known CAD amenable to CABG and LV ejection fraction <35% were randomized to medical therapy alone versus CABG plus medical therapy with an average follow-up of five years. The primary outcome of death from any cause occurred in 41% of the medical-therapy-alone group and 36% of the CABG-plus-medical-therapy group (hazard ratio with CABG 0.86; 95% CI 0.72 to 1.04; P=0.12).
Despite subgroup analysis suggesting decreased death rates from cardiovascular causes in the latter group, there was no significant difference in the primary endpoint of death from any cause.
Bottom line: The addition of CABG to medical therapy for patients with CAD and left ventricular dysfunction does not decrease mortality.