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PREDICTORS OF ADVERSE EVENTS IN PREDICTORS OF ADVERSE EVENTS IN

PATIENTS WITH UNPROTECTED LEFT PATIENTS WITH UNPROTECTED LEFT

MAIN DISEASE TREATED WITH DRUG-MAIN DISEASE TREATED WITH DRUG-

ELUTING STENTS: EVIDENCE FROM A ELUTING STENTS: EVIDENCE FROM A

COLLABORATIVE META-REGRESSIONCOLLABORATIVE META-REGRESSION

G. BIONDI-ZOCCAI1, C. MORETTI1, E. MELIGA1, P. AGOSTONI2,

A. ABBATE3, M. VALGIMIGLI4, G. SANGIORGI5, G. TREVI1

AND I. SHEIBAN1

1University of Turin, Turin, Italy (gbiondizoccai@gmail.com); 2AZ Middelheim,

Antwerp, Belgium; 3Virginia Commonwealth University, Virginia, USA; 4University

of Ferrara, Ferrara, Italy; 5Emo Centro Cuore Columbus, Milano,Italy

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BACKGROUND

• Percutaneous drug-eluting stenting (DES) is being increasingly adopted as treatment for selected patients with unprotected left main coronary disease (ULM)

• Evidence on predictors of adverse events, pivotal for such patient selection, is lacking to date

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OBJECTIVES

• To perform a systematic review of the outcomes of DES implantation in patients with ULM coronary disease

• To pool major outcomes with meta-analytic techniques

• To identify predictors of adverse events by means of meta-regression analysis

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METHODS

• Several databases (BioMedCentral, clinicaltrials.gov, Google Scholar, and PubMed) were systematically searched for pertinent clinical studies published up to November 2006

• Major selection criteria were:– enrolment of at least 20 patients– follow-up for at least 6 months– full text publication (thus excluding abstracts)

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METHODS

• Pre-specified subgroup analyses were performed according to ostial ULM, and non-high-risk features (defined by means of Parsonnet or EuroSCORE systems)

• Generic-inverse-variance random-effect methods were used to pool incidence rates and adjusted risk estimates (95% confidence intervals)

• Meta-regression was performed to identify regression coefficients (with 95% confidence intervals) for event predictors

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REVIEW PROFILE

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RESULTS

• After excluding 806 non-pertinent citations, we finally included 16 original studies (1274 patients, median follow-up 9 months [range 6-24])

• There were 8 uncontrolled reports on DES, 5 non-randomized comparison between DES and bare-metal stents (BMS), and 3 between DES and CABG

• Overall, 31% of patients had non-bifurcational ULM and 59.5% had high-risk features at EuroSCORE or Parsonnet

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RESULTS

• Mid-term MACE occurred in 18.2%, mid-term death in 4.4%, and repeat revascularization in 7.4%

• Meta-regression showed that location of disease (ie non-bifurcational vs bifurcational ULM) was the most significant predictor of mid-term MACE (p=0.001) as well as of repeat revascularization (p=0.020)

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RESULTS

• Intriguingly, disease location explained the vast majority of MACE risk across different patients and studies (R=-0.76, R2=0.58)

• On the other hand, high-risk features at EuroSCORE or Parsonnet were the most significant predictor of mid-term death (p=0.027)

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RISK OF MACE AT FOLLOW-UP

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META-REGRESSION

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META-REGRESSION

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META-REGRESSION

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CONCLUSIONS

• Analysis of the largest cohort to date of patients treated with DES for ULM shows that risk-stratification should be based in these patients on location of disease and overall risk features

• In particular, event-free survival is excellent in low-risk patients with non-bifurcational ULM, while a high case fatality can be expected in high-risk subjects, irrespective of disease location

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