Prior Cerebrovascular Disease: A Key Factor In The Assessment for Optimal Left Main Coronary Artery Revascularization Strategy Results From the EXCEL Trial

A study conducted by Dr. Gregg W.Stone and his colleagues from Columbia University Medical Center demonstrated that patients with left main coronary artery disease (LMCAD) and prior cerebrovascular disease (CEVD) compared with those without CEVD have higher rates of stroke and reduced event-free survival after revascularization. In their publication in JACC: Cardiovascular Interventions, they stated that PCI need not be a priori preferred over CABG for LMCAD in patients with known CEVD.  Patients with CEVD should undergo evaluation for both PCI and CABG, with careful consideration of comorbidities, the likelihood of safely achieving complete revascularization, and patient preferences in order to determine the optimal coronary revascularization strategy.

Patients with prior CEVD represent a high-risk group that has worse outcomes after coronary revascularization than patients without CEVD. Currently, there are no established guidelines for the optimal coronary revascularization strategy for patients with CEVD. Because most randomized trials have demonstrated a higher perioperative stroke risk after coronary artery bypass grafting (CABG) compared with percutaneous coronary intervention (PCI), patients with CEVD are often preferentially referred to PCI for coronary  revascularization; however, patients with CEVD often have more comorbidities and more extensive CAD compared with those without CEVD, and outcomes after PCI in such patients may be lessfavorablee. Although patients with known CEVD requiring revascularization are often referred to PCI rather than CABG, the authors noted a paucity of data regarding the impact of CEVD in patients with LMCAD undergoing revascularization. Therefore, the aim of this study was to determine whether high-risk patients with left main coronary artery disease (LMCAD) and prior cerebrovascular disease (CEVD) preferentially benefited from revascularization by percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG).

In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with LMCAD and low or intermediate SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) scores were randomized to PCI with everolimus-eluting stents versus CABG. The effects of prior CEVD, defined as prior stroke, transient ischemic attack, or carotid artery disease, on 30-day and 3-year event rates were evaluated. The investigators found that prior CEVD was present in 233 of 1,898 patients (12.3%). These patients were older and had higher rates of comorbidities, including hypertension, diabetes, peripheral vascular disease, anemia, chronic kidney disease, and prior PCI, compared with those without prior CEVD. Patients with prior CEVD had higher rates of stroke at 30 days (2.2% vs. 0.8%; p ¼ 0.05) and 3 years (6.4% vs. 2.2%; p ¼ 0.0003) and higher 3-year rates of the primary endpoint of all-cause death, stroke, or myocardial infarction (25.0% vs. 13.6%; p < 0.0001). Additionally, the relative effects of PCI versus CABG on the 30-day and 3-year rates of stroke (p interaction ¼ 0.65 and 0.16, respectively) and the 3-year rates of the primary composite endpoint (p interaction ¼ 0.14) were consistent in patients with and those without prior CEVD.

The investigators drew the conclusion that known CEVD in patients with LMCAD was a major risk factor for periprocedural and late recurrent stroke and death after revascularization; however, although periprocedural stroke occurred less frequently after PCI than CABG, data from EXCEL did not support a preferential role of PCI over CABG in patients with known CEVD. Rather, the investigators recommended that prior CEVD should be one of many factors considered in the comprehensive heart team assessment of patients with LMCAD requiring revascularization. Novel approaches to improve the prognosis of high-risk patients with LMCAD and prior CEVD were warranted. Echoing their sentiments, Dr. Seung-Jung Park, University of Ulsan College of Medicine, Seoul, South Korea noted, “In conclusion, considering the increasing prevalence of CVD among patients requiring myocardial revascularization, the optimal decision-making of revascularization strategies and the optimal peri- and post-operative management of patients with concomitant CVD may pose the clinically relevant “unmet issue” for treating patients with LMCA disease. Concomitant CVD should be considered a key factor in the comprehensive heart team assessment for optimal LMCA revascularization and, particularly for patients at high risk for perioperative stroke after revascularization, such as elderly patients or patients with previous TIA/stroke, specific screening, and preventive measures should be suggested.” Speaking of the next steps, Dr. Duk-Woo Park stated, “It should be discussed whether the highest spectrum of patients with CVD (i.e., patients with disabling strokes, recent [<6 months] history of stroke/TIA, or severe residual neurological defects) would preferentially benefit from PCI rather than CABG. Finally, more studies should be performed to evaluate the role of pre-procedural stroke-risk screening (i.e., routine carotid Doppler ultrasound, computed tomography scan screening, other brain imaging, or routine neurological examination) for better risk stratification and to determine specific preventive measures (i.e., medical, procedural, or surgical strategies) for reducing early and late stroke events after revascularization.