Comprehensive analysis of medical and invasive treatment strategies for patients with significant left anterior descending artery disease (COMMIT-LAD): an interim analysis update

Introduction

Adequate knowledge of the physiological impact and morphological pattern of coronary artery disease (CAD) optimizes therapeutic strategy selection. Hemodynamically significant focal lesions are relatively often effectively treated with percutaneous coronary intervention (PCI), whereas diffusely diseased vessels more frequently warrant coronary artery bypass grafting (CABG) or optimal medical therapy (OMT). Clinicians increasingly use pullback measurements to assess disease patterns and improve percutaneous interventions, but the influence on clinical decision-making is relatively unknown.

Purpose

This ongoing prospective, multicenter registry aims to gain insights on a coronary physiology based treatment strategy by evaluating the relative effectiveness of surgical versus pharmacological treatment strategies for patients with CAD. It also assesses how these three strategies affect the quality of life and angina status up until 1 year of follow-up.

Methods

This registry recruits patients with hemodynamically significant (Fractional Flow Reserve [FFR} ≤ 0.80, Resting Full-cycle Ratio [RFR] ≤ 0.89) left anterior descending artery (LAD) disease with an involvement of the proximal segment.

The COMMIT-LAD group comprises patients with diffuse LAD disease, as proven by a RFR pullback, who had undergone OMT or CABG, and patients with proven focal disease who were treated with Optical Coherence Tomography (OCT) guided PCI. The standard group comprises patients who have not undergone such measurements or whose treatment plan deviates from the results of those measurements.

During follow-up assessments at 1, 3, 6 and 12 months, major adverse cardiovascular events (MACE) serve as a primary endpoint, while the quality of life and angina score, serve as secondary endpoints.

Results

213 patients have been enrolled in this registry: 64 in the standard group and 149 in the COMMIT-LAD group. Aside from the greater representation of men in the COMMIT-LAD group, the baseline characteristics of the participants are similar across both groups, as is shown in Table 1.

To date, 9 MACE events (6.0%) have occurred in the COMMIT-LAD group, compared with 4 events (9.4%) in the standard group. In the standard group, PCI is more frequent, while CABG and OMT are less common (PCI: 82.3% vs 24.2%; CABG: 11.3% vs 39.4%; OMT: 6.5% vs 36.4%; standard vs COMMIT-LAD; p<0.0001).

Conclusion

Intracoronary functional measurements in stable CAD with hemodynamically significant LAD disease favor CABG and OMT over PCI. This updated interim analysis emphasised the role of plaque burden assessment in treatment decisions. The completed data will provide more insights into it’s impact on clinical outcomes and quality of life.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.