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Left main coronary artery disease: pathophysiology, diagnosis, and treatment

This article has been updated

Abstract

The advent of coronary angiography in the 1960s allowed for the risk stratification of patients with stable angina. Patients with unprotected left main coronary artery disease have an increased risk of death related to the large amount of myocardium supplied by this vessel. Although coronary angiography remains the preferred imaging modality for the evaluation of left main coronary artery stenosis, this technique has important limitations. Angiograms of the left main coronary artery segment can be difficult to interpret, and almost one-third of patients can be misclassified when fractional flow reserve is used as the reference. In patients with clinically significant unprotected left main coronary artery disease, surgical revascularization was shown to improve survival compared with medical therapy and has been regarded as the treatment of choice for unprotected left main coronary artery disease. Two large-scale clinical trials published in 2016 support the usefulness of catheter-based revascularization in selected patients with unprotected left main coronary artery disease. In this Review, we describe the pathophysiology of unprotected left main coronary artery disease, discuss diagnostic approaches in light of new noninvasive and invasive imaging techniques, and detail risk stratification models to aid the Heart Team in the decision-making process for determining the best revascularization strategy for these patients.

Key points

Patients with unprotected left main coronary artery disease have an increased risk of death

Although coronary angiography remains the preferred diagnostic imaging modality for these patients, adjunctive anatomical and physiological methods are often required to assess the clinical significance of the lesion

In patients with unprotected left main coronary artery disease, surgical revascularization was shown to improve survival compared with medical therapy

The EXCEL and NOBLE trials demonstrated the safety and efficacy of percutaneous coronary intervention compared with CABG surgery in selected patients with unprotected left main coronary artery disease

Long-term clinical follow-up is required to define the optimal clinical management of patients with unprotected left main coronary artery disease

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Fig. 1: Timeline of myocardial revascularization in left main coronary artery disease.
Fig. 2: Role of endothelial shear stress in atherosclerotic plaque formation in the left main coronary bifurcation.
Fig. 3: Assessment of the physiological interdependency in the coronary tree.
Fig. 4: PCI bifurcation techniques for patients with unprotected left main coronary artery disease.
Fig. 5: PCI versus CABG surgery in patients with left main coronary artery disease.

Change history

  • 21 February 2020

    This article has been modified to correct the resolution of the arrows depicting shear stress in Figure 2. The figure has been updated in the HTML and PDF versions of the manuscript.

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Nature Reviews Cardiology thanks Y.-H. Kim, R. Waksman, W. Wijns, and the other anonymous reviewer(s) for their contribution to the peer review of this work.

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C.C. researched the data for the article. C.C. and P.W.S. discussed the content of the manuscript. C.C., D.C., G.W.S., and P.W.S. wrote the article. C.C., Y.O., A.B., G.W.S., D.P.T., and J.S. reviewed and/or edited the manuscript before submission.

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Correspondence to Patrick W. Serruys.

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Competing interests

C.C. received research grants from Biosensors and HeartFlow. D.C. received speaker and consulting honoraria from Abbott Vascular, AstraZeneca, Bayer, Daiichi Sankyo, and Stentys. Y.O. is a member of the advisory board of Abbott Vascular. A.B. received lecture fees from Abbott Vascular, Boston Scientific, and Medtronic and grant support from Boston Scientific. G.W.S. received consulting fees from Ablative Solutions, Matrizyme, Medical Development Technologies, Miracor, Neovasc, TherOx, Reva, Toray, Vascular Dynamics, Velomedix, and V-Wave; served as a consultant on prasugrel patent litigation paid for by Lupin Pharmaceuticals; and holds equity, stock options, or both in the Aria, Biostar family of funds, Cagent, Caliber Therapeutics, Guided Delivery Systems, MedFocus family of funds, MiCardia, Qool Therapeutics, and Vascular Nanotransfer Technologies. Columbia University (G.W.S.) received royalties from Abbott Vascular for the sale of MitraClip. D.P.T. served as advisor and speaker for Abbott Laboratories, Medtronic, and Novadaq Technologies; and owns stock, stock option, or bonds from Novadaq Technologies. J.S. received fees for serving on advisory boards from Medtronic and the Sorin Group, training fees from Medtronic, and research funding from Abbott and Edwards Lifesciences. P.W.S. received consulting fees from Abbott, AstraZeneca, Biotronik, Cardialysis, GLG Research, Medtronic, SINO Medical Sciences Technology, St. Jude Medical, Stentys France, Svelte Medical Systems, and Volcano.

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Glossary

Right dominant coronary circulation

A circulation pattern in which the posterior descending artery, which supplies the myocardium of the inferior one-third of the interventricular septum, is a branch of the right coronary artery.

Fractional flow reserve

The ratio of distal coronary pressure to aortic pressure during hyperaemia; linearly and strongly correlates to the ratio of stenotic-to-normal mean arterial Doppler-derived blood flow velocity.

Heart Team

Multidisciplinary approach for revascularization; made up of an interventional cardiologist, a cardiac surgeon, and often the patient’s general cardiologist.

Carina

Arterial region between the division of the main and side branch, where blood flow diverts and deflects.

Shear stress

The tangential force derived from the friction of the flowing blood on the endothelial surface.

Duke treadmill score

Weighted index combining treadmill exercise time using the standard Bruce protocol, maximum net ST-segment deviation (depression or elevation), and exercise-induced angina.

Intravascular ultrasonography

Imaging methodology using a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter to assess the coronary artery.

Instantaneous wave-free ratio

Nonhyperaemic ratio of distal coronary pressure to aortic pressure during the diastolic wave-free period.

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Collet, C., Capodanno, D., Onuma, Y. et al. Left main coronary artery disease: pathophysiology, diagnosis, and treatment. Nat Rev Cardiol 15, 321–331 (2018). https://doi.org/10.1038/s41569-018-0001-4

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