title: Comparative outcomes after unprotected left main stem percutaneous coronary intervention: a national linked cohort study of 5,065 acute and elective cases from the BCIS Registry (British Cardiovascular Intervention Society).
abstract: OBJECTIVE
  The goal of this study was to report outcomes from percutaneous coronary intervention (PCI) to an unprotected left main stem (UPLMS) stenosis according to presenting syndrome, including ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation acute coronary syndrome (NSTEACS), and chronic stable angina (CSA).
  
  
  BACKGROUND
  There are no published whole-country data concerning patient outcomes following PCI to UPLMS.
  
  
  METHODS
  This study is a prospective national cohort study using data from the British Cardiovascular Intervention Society (BCIS) registry from January 1, 2005, through December 31, 2010.
  
  
  RESULTS
  Of 5,065 patients having PCI to an UPLMS, 784 (15.5%) presented with STEMI, 2,381 (47.0%) with NSTEACS, and 1,900 (37.5%) with CSA. Crude 30-day and 1-year mortality rates were STEMI: 28.3% and 37.6%, NSTEACS: 8.9% and 19.5%, and CSA: 1.4% and 7.0%, respectively. Unadjusted in-hospital major adverse cardiovascular and cerebrovascular event rates were STEMI: 26.6%, NSTEACS: 6.6%, and CSA: 3.3%. Risk of 30-day mortality was much greater for STEMI and NSTEACS patients than CSA (STEMI adjusted odds ratio [aOR]: 29.45, 95% confidence interval [CI]: 19.37 to 44.80, NSTEACS aOR: 6.45, 95% CI: 4.27 to 9.76). More than 40% of patients presenting with STEMI had cardiogenic shock, in whom mortality was higher than in STEMI cases without shock (30 days: 52.0% vs. 11.7%, 1 year: 61.1% vs. 20.9%). Radial access, compared with the femoral approach, was associated with a lower risk of 30-day mortality (STEMI aOR: 0.37, 95% CI: 0.21 to 0.62; NSTEACS aOR: 0.66, 95% CI: 0.45 to 0.97).
  
  
  CONCLUSIONS
  More than one-half of the patients who received UPLMS PCI were acute where outcomes were much worse than elective cases. Cardiogenic shock is common in STEMI patients, of whom more than one-half die at 30 days. The radial approach was associated with reduced early mortality in acute cases.
authors: Division of Epidemiology and Biostatistics, University of Leeds, Leeds, United Kingdom. Electronic address: umssal@leeds.ac.uk.
authors: Sami S
authors: SS
authors: Almudarra
authors: Division of Epidemiology and Biostatistics, University of Leeds, Leeds, United Kingdom; Department of Cardiology, York Teaching Hospital NHS Foundation Trust, York, United Kingdom.
authors: Chris P
authors: CP
authors: Gale
authors: Division of Epidemiology and Biostatistics, University of Leeds, Leeds, United Kingdom.
authors: Paul D
authors: PD
authors: Baxter
authors: Division of Epidemiology and Biostatistics, University of Leeds, Leeds, United Kingdom.
authors: Sarah J
authors: SJ
authors: Fleming
authors: Division of Epidemiology and Biostatistics, University of Leeds, Leeds, United Kingdom; Department of Cardiology, York Teaching Hospital NHS Foundation Trust, York, United Kingdom.
authors: Richard A
authors: RA
authors: Brogan
authors: Department of Cardiology, University Hospital Birmingham National Health Service (NHS) Foundation Trust, Birmingham, United Kingdom.
authors: Peter F
authors: PF
authors: Ludman
authors: Department of Cardiology, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom.
authors: Mark A
authors: MA
authors: de Belder
authors: Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; The Coronary Research Group, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.
authors: Nick P
authors: NP
authors: Curzen
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D060050:Angina, Stable / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D002561:Cerebrovascular Disorders / Q000209:etiology / Q000401:mortality; D016009:Chi-Square Distribution; D057186:Comparative Effectiveness Research; D005260:Female; D005263:Femoral Artery; D006801:Humans; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods / Q000401:mortality; D016016:Proportional Hazards Models; D011446:Prospective Studies; D017534:Radial Artery; D012042:Registries; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000209:etiology / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom
keywords: NSTEACS; STEMI; acute myocardial infarction; adjusted odds ratio(s); chronic stable angina; confidence interval(s); mortality; multiple imputation; outcome; percutaneous coronary intervention; survival; unprotected left main stem