Management of significant proximal left anterior descending coronary artery disease
- Malcolm R Bell, MBBS, FRACP, FACC
Malcolm R Bell, MBBS, FRACP, FACC
- Professor of Medicine
- Mayo Medical School
- John A Bittl, MD
John A Bittl, MD
- Munroe Heart and Vascular Institute
- Munroe Regional Medical Center
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
The prognosis of patients with coronary artery disease is related to the extent of myocardium at risk. Proximal left anterior descending coronary artery (LAD) lesions often supply a high percentage of the left ventricular myocardium, compared to proximal lesions in the circumflex or right coronary arteries. A study reported that the prevalence of significant proximal LAD disease in stable patients undergoing diagnostic coronary catheterization was 7.2 percent in New York State and 13.4 percent in Ontario, Canada .
This topic will discuss both the choice between medical therapy and revascularization for treatment of proximal LAD disease in stable patients as well as the choice between coronary artery bypass graft surgery and percutaneous coronary intervention in those patients in whom revascularization is chosen. This discussion will focus on the outcomes of survival, myocardial infarction, and revascularization rates. Revascularization to improve angina refractory to medical therapy in patients for whom survival will not be improved is discussed separately. (See "Stable ischemic heart disease: Indications for revascularization" and "Stable ischemic heart disease: Overview of care".)
The management of patients with stable, nonproximal LAD disease is similar to disease identified in the circumflex and right coronary arteries. (See "Stable ischemic heart disease: Indications for revascularization" and "Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention".)
The discussion of coronary artery revascularization in the large subgroup of patients with diabetes is found elsewhere. (See "Coronary artery revascularization in patients with diabetes mellitus and multivessel coronary artery disease".)
DEFINITION OF SIGNIFICANT
For the purposes of this topic, significant disease of the proximal (proximal to and including the first major septal branch) left anterior descending coronary artery is present when coronary angiography reveals one or more obstructive lesions and one of the following criteria:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Ko DT, Tu JV, Austin PC, et al. Prevalence and extent of obstructive coronary artery disease among patients undergoing elective coronary catheterization in New York State and Ontario. JAMA 2013; 310:163.
- Hachamovitch R, Hayes SW, Friedman JD, et al. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation 2003; 107:2900.
- Tarakji KG, Brunken R, McCarthy PM, et al. Myocardial viability testing and the effect of early intervention in patients with advanced left ventricular systolic dysfunction. Circulation 2006; 113:230.
- Yusuf S, Zucker D, Peduzzi P, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994; 344:563.
- Alderman EL, Fisher LD, Litwin P, et al. Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation 1983; 68:785.
- O'Connor CM, Velazquez EJ, Gardner LH, et al. Comparison of coronary artery bypass grafting versus medical therapy on long-term outcome in patients with ischemic cardiomyopathy (a 25-year experience from the Duke Cardiovascular Disease Databank). Am J Cardiol 2002; 90:101.
- Patel MR, Dehmer GJ, Hirshfeld JW, et al. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012; 59:857.
- Greenbaum AB, Califf RM, Jones RH, et al. Comparison of medicine alone, coronary angioplasty, and left internal mammary artery-coronary artery bypass for one-vessel proximal left anterior descending coronary artery disease. Am J Cardiol 2000; 86:1322.
- Brener SJ, Lytle BW, Casserly IP, et al. Predictors of revascularization method and long-term outcome of percutaneous coronary intervention or repeat coronary bypass surgery in patients with multivessel coronary disease and previous coronary bypass surgery. Eur Heart J 2006; 27:413.
- Lytle BW, Loop FD, Taylor PC, et al. The effect of coronary reoperation on the survival of patients with stenoses in saphenous vein bypass grafts to coronary arteries. J Thorac Cardiovasc Surg 1993; 105:605.
- Subramanian S, Sabik JF 3rd, Houghtaling PL, et al. Decision-making for patients with patent left internal thoracic artery grafts to left anterior descending. Ann Thorac Surg 2009; 87:1392.
- Coronary angioplasty versus coronary artery bypass surgery: the Randomized Intervention Treatment of Angina (RITA) trial. Lancet 1993; 341:573.
- Rodriguez A, Boullon F, Perez-Baliño N, et al. Argentine randomized trial of percutaneous transluminal coronary angioplasty versus coronary artery bypass surgery in multivessel disease (ERACI): in-hospital results and 1-year follow-up. ERACI Group. J Am Coll Cardiol 1993; 22:1060.
- Hamm CW, Reimers J, Ischinger T, et al. A randomized study of coronary angioplasty compared with bypass surgery in patients with symptomatic multivessel coronary disease. German Angioplasty Bypass Surgery Investigation (GABI). N Engl J Med 1994; 331:1037.
- King SB 3rd, Lembo NJ, Weintraub WS, et al. A randomized trial comparing coronary angioplasty with coronary bypass surgery. Emory Angioplasty versus Surgery Trial (EAST). N Engl J Med 1994; 331:1044.
- First-year results of CABRI (Coronary Angioplasty versus Bypass Revascularisation Investigation). CABRI Trial Participants. Lancet 1995; 346:1179.
- Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 1996; 335:217.
- Pocock SJ, Henderson RA, Rickards AF, et al. Meta-analysis of randomised trials comparing coronary angioplasty with bypass surgery. Lancet 1995; 346:1184.
- Goy JJ, Kaufmann U, Goy-Eggenberger D, et al. A prospective randomized trial comparing stenting to internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis: the SIMA trial. Stenting vs Internal Mammary Artery. Mayo Clin Proc 2000; 75:1116.
- Goy JJ, Eeckhout E, Burnand B, et al. Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis. Lancet 1994; 343:1449.
- Goy JJ, Eeckhout E, Moret C, et al. Five-year outcome in patients with isolated proximal left anterior descending coronary artery stenosis treated by angioplasty or left internal mammary artery grafting. A prospective trial. Circulation 1999; 99:3255.
- Sawhney N, Moses JW, Leon MB, et al. Treatment of left anterior descending coronary artery disease with sirolimus-eluting stents. Circulation 2004; 110:374.
- Dangas G, Ellis SG, Shlofmitz R, et al. Outcomes of paclitaxel-eluting stent implantation in patients with stenosis of the left anterior descending coronary artery. J Am Coll Cardiol 2005; 45:1186.
- Seung KB, Kim YH, Park DW, et al. Effectiveness of sirolimus-eluting stent implantation for the treatment of ostial left anterior descending artery stenosis with intravascular ultrasound guidance. J Am Coll Cardiol 2005; 46:787.
- Serruys PW, Unger F, Sousa JE, et al. Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med 2001; 344:1117.
- Bhatt DL, Topol EJ. Debate: PCI or CABG for multivessel disease? Viewpoint: No clear winner in an unfair fight. Curr Control Trials Cardiovasc Med 2001; 2:260.
- Hannan EL, Racz MJ, Walford G, et al. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med 2005; 352:2174.
- Rodriguez A, Rodríguez Alemparte M, Baldi J, et al. Coronary stenting versus coronary bypass surgery in patients with multiple vessel disease and significant proximal LAD stenosis: results from the ERACI II study. Heart 2003; 89:184.
- Aoki J, Ong AT, Arampatzis CA, et al. Comparison of three-year outcomes after coronary stenting versus coronary artery bypass grafting in patients with multivessel coronary disease, including involvement of the left anterior descending coronary artery proximally (a subanalysis of the arterial revascularization therapies study trial). Am J Cardiol 2004; 94:627.
- Kukreja N, Serruys PW, De Bruyne B, et al. Sirolimus-eluting stents, bare metal stents or coronary artery bypass grafting for patients with multivessel disease including involvement of the proximal left anterior descending artery: analysis of the Arterial Revascularization Therapies study part 2 (ARTS-II). Heart 2009; 95:1061.
- Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360:961.
- Goy JJ, Kaufmann U, Hurni M, et al. 10-year follow-up of a prospective randomized trial comparing bare-metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial. J Am Coll Cardiol 2008; 52:815.
- Kapoor JR, Gienger AL, Ardehali R, et al. Isolated disease of the proximal left anterior descending artery comparing the effectiveness of percutaneous coronary interventions and coronary artery bypass surgery. JACC Cardiovasc Interv 2008; 1:483.
- Aziz O, Rao C, Panesar SS, et al. Meta-analysis of minimally invasive internal throacic artery bypaas versus percutaneous revascularisation. BMJ 2007; 334:593.
- Aziz O, Rao C, Panesar SS, et al. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ 2007; 334:617.
- Diegeler A, Thiele H, Falk V, et al. Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery. N Engl J Med 2002; 347:561.
- Drenth DJ, Veeger NJ, Winter JB, et al. A prospective randomized trial comparing stenting with off-pump coronary surgery for high-grade stenosis in the proximal left anterior descending coronary artery: three-year follow-up. J Am Coll Cardiol 2002; 40:1955.
- Thiele H, Oettel S, Jacobs S, et al. Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: a 5-year follow-up. Circulation 2005; 112:3445.
- Thiele H, Neumann-Schniedewind P, Jacobs S, et al. Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis. J Am Coll Cardiol 2009; 53:2324.
- Hannan EL, Zhong Y, Walford G, et al. Coronary artery bypass graft surgery versus drug-eluting stents for patients with isolated proximal left anterior descending disease. J Am Coll Cardiol 2014; 64:2717.
- Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44.
- Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2610.
- Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541.