title: Unprotected left main revascularization in patients with acute coronary syndromes.
abstract: OBJECTIVE
  In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary disease (ULMCD) has been little studied. The objectives of the present study were to describe the practice of ULMCD revascularization in ACS patients and its evolution over an 8-year period, analyse the prognosis of this population and determine the effect of revascularization on outcome.
  
  
  RESULTS
  Of 43 018 patients enrolled in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007, 1799 had significant ULMCD and underwent percutaneous coronary intervention (PCI) alone (n = 514), coronary artery bypass graft (CABG) alone (n = 612), or no revascularization (n = 673). Mortality was 7.7% in hospital and 14% at 6 months. Over the 8-year study, the GRACE risk score remained constant, but there was a steady shift to more PCI than CABG over time. Patients undergoing PCI presented more frequently with ST-segment elevation myocardial infarction (STEMI), after cardiac arrest, or in cardiogenic shock; 48% of PCI patients underwent revascularization on the day of admission vs. 5.1% in the CABG group. After adjustment, revascularization was associated with an early hazard of hospital death vs. no revascularization, significant for PCI (hazard ratio (HR) 2.60, 95% confidence interval (CI) 1.62-4.18) but not for CABG (1.26, 0.72-2.22). From discharge to 6 months, both PCI (HR 0.45, 95% CI 0.23-0.85) and CABG (0.11, 0.04-0.28) were significantly associated with improved survival in comparison with an initial strategy of no revascularization. Coronary artery bypass graft revascularization was associated with a five-fold increase in stroke compared with the other two groups.
  
  
  CONCLUSIONS
  Unprotected left main coronary disease in ACS is associated with high mortality, especially in patients with STEMI and/or haemodynamic or arrhythmic instability. Percutaneous coronary intervention is now the most common revascularization strategy and preferred in higher risk patients. Coronary artery bypass graft is often delayed and performed in lower risk patients, leading to good 6-month survival. The two approaches therefore appear complementary.
authors.affiliation: Institut de Cardiologie, Bureau 2-236, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47 Blvd de l'Hôpital, 75013 Paris, France. gilles.montalescot@psl.aphp.fr
authors.forename: Gilles
authors.initials: G
authors.lastname: Montalescot
authors.forename: David
authors.initials: D
authors.lastname: Brieger
authors.forename: Kim A
authors.initials: KA
authors.lastname: Eagle
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Anderson
authors.forename: Gordon
authors.initials: G
authors.lastname: FitzGerald
authors.forename: Michael S
authors.initials: MS
authors.lastname: Lee
authors.forename: Ph Gabriel
authors.initials: PG
authors.lastname: Steg
authors.forename: Alvaro
authors.initials: A
authors.lastname: Avezum
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
authors.forename: Joel M
authors.initials: JM
authors.lastname: Gore
mesh_terms: D054058:Acute Coronary Syndrome / Q000628:therapy*; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000379:methods; D001026:Coronary Artery Bypass / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D009204:Myocardial Revascularization / Q000379:methods*; D012042:Registries; D012770:Shock, Cardiogenic / Q000628:therapy; D015607:Stents; D020521:Stroke / Q000209:etiology