Abstract

Background: Severe left main coronary artery disease (LMD) poses a major treatment challenge in Latin America, where both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are used. Methods: This guideline was developed de novo using the GRADE approach. A multidisciplinary panel reviewed evidence from a systematic review of randomized trials comparing PCI and CABG, incorporating a comprehensive literature search of patient values and preferences and outcome utilities. Thresholds were assigned for each clinical outcome, from small to large effect. Results: Five randomized trials enrolling 4612 patients were included. At 30 days, PCI resulted in a large reduction in major bleeding and a small reduction in strokes. At 5 years, PCI was associated with a small to moderate increase of spontaneous myocardial infarction and a moderate to large increase in repeat revascularization. No important differences in short-or long-term mortality were observed between PCI and CABG. The overall certainty of evidence was rated low. There was a notable variability in patient values and a close call on the balance of effects. Conclusions: For patients in Latin America with severe left main coronary artery disease, the guideline panel suggests either PCI or CABG. This is a conditional recommendation, based on low certainty in the evidence ((R)(R)circle circle). It applies when both procedures are clinically and anatomically appropriate and can be performed at centers meeting acceptable standards. The decision should be made through a shared decision-making process involving the patient and the multidisciplinary care team.