Impact of Angiographic Complete Revascularization After Drug-Eluting Stent Implantation or Coronary Artery Bypass Graft Surgery for Multivessel Coronary Artery Disease

Cardiac Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
Circulation (Impact Factor: 14.43). 05/2011; 123(21):2373-81. DOI: 10.1161/CIRCULATIONAHA.110.005041
Source: PubMed


This study sought to evaluate the clinical impact of angiographic complete revascularization (CR) after drug-eluting stent implantation or coronary artery bypass graft surgery for multivessel coronary disease.
A total of 1914 consecutive patients with multivessel coronary disease undergoing drug-eluting stent implantation (1400 patients) or coronary artery bypass graft surgery (514 patients) were enrolled. Angiographic CR was defined as revascularization in all diseased segments according to the Synergy Between PCI With Taxus and Cardiac Surgery classification. The outcomes of patients undergoing CR were compared with those undergoing incomplete revascularization (IR) after adjustments with the inverse-probability-of-treatment weighting method. Angiographic CR was performed in 917 patients (47.9%) including 573 percutaneous coronary intervention (40.9%) and 344 coronary artery bypass graft (66.9%) patients. CR patients were younger and had more extensive coronary disease than IR patients. Over 5 years, CR patients had comparable incidences of death (8.9% versus 8.9%; adjusted hazard ratio, 1.04; 95% confidence interval, 0.76 to 1.43; P=0.81), the composite of death, myocardial infarction, and stroke (12.1% versus 11.9%; adjusted hazard ratio, 1.04; 95% confidence interval, 0.79 to 1.36; P=0.80), and the composite of death, myocardial infarction, stroke, and repeat revascularization (22.4% versus 24.9%; adjusted hazard ratio, 0.91; 95% confidence interval, 0.75 to 1.10; P=0.32) compared with IR patients. However, 368 patients (19.2%) with multivessel IR had a greater tendency toward higher risk of death, myocardial infarction, stroke, or repeat revascularization (30.3% versus 22.1%; adjusted hazard ratio, 1.27; 95% confidence interval, 0.97 to 1.66; P=0.079) than those without multivessel IR.
Angiographic CR with drug-eluting stent implantation or coronary artery bypass grafting did not improve long-term clinical outcomes in patients with multivessel disease. This finding supports the strategy of ischemia-guided revascularization.

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    • "In the bare metal stent era, IR might be associated with higher risk of long-term mortality in patients with multi-vessel disease.[7] But in drug-eluting stent era, some studies argue that angiographic CR seems not to improve long-term clinical outcomes.[8],[9] Consequently, we doubt the necessity of CR in complex cases, and we hypothesized that IR may permit meaningful long-term results in selected high risk patients with severe and multiple coronary artery disease and complex clinical co-morbidities. "
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    ABSTRACT: To compare long-term prognosis between complete revascularization (CR) and incomplete revascularization (IR) in elderly patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI). We prospectively enrolled patients ≥ 75 years with ACS and multi-lesion disease between January 2005 and December 2010 at our center (Institute of Geriatric Cardiology, Chinese PLA General Hospital). Baseline clinical characteristics, PCI parameters and long-term (12 to 78 months) outcomes including main adverse cardiac and cerebral events (MACCE) were compared between CR and IR groups. We used the Kaplan-Meier curve to describe the survival rates, and variables reported to be associated with prognosis were included in Cox regression. Of the 502 patients, 230 patients obtained CR, and the other 272 patients underwent IR. Higher SYNTAX score was an independent predictor of IR [Odds ratio (OR): 1.141, 95% confidence interval (95% CI): 1.066-1.221, P = 0.000]. A total of 429 patients (85.5%) were followed with a duration ranging from 12 months to 78 months. There were no significant differences in cumulative survival rates and event free survival rates between the two groups, even for patients with multi-vessel disease. Older age (OR: 1.079, 95% CI: 1.007-1.157, P = 0.032), prior myocardial infarction (OR: 1.440, 95% CI: 1.268-2.723, P = 0.001) and hypertension (OR: 1. 653, 95% CI: 1.010-2.734, P = 0.050) were significant independent predictors of long-term MACCE. Given that both clinical and coronary lesion characteristics are much more complex in patients ≥75 years with ACS and multi-lesion disease, IR may be an option allowing low risk hospital results and meaningful long-term (12 to 78 months) outcomes.
    Full-text · Article · Dec 2012 · Journal of Geriatric Cardiology

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    ABSTRACT: To assess whether incomplete revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) has an effect on long-term outcomes. During a heart team discussion to evaluate whether patients were eligible for randomization in the SYNTAX trial, both the cardiologist and surgeon agreed on which vessels needed revascularization. This statement was compared with the actual revascularization after treatment. Incomplete revascularization was defined as when a preoperatively identified vessel with a lesion was not revascularized. Outcomes were major adverse cardiac or cerebrovascular events (MACCE), the composite safety endpoint of death/stroke/myocardial infarction (MI), and individual MACCE components death, MI and repeat revascularization at 3 years. Predictors of incomplete revascularization were explored. Incomplete revascularization was found in 43.3% (388/896) PCI and 36.8% (320/870) CABG patients. Patients with complete revascularization by PCI had lower rates of MACCE (66.5 versus 76.2%, P < 0.001), the composite safety endpoint (83.4 versus 87.9%, P = 0.05) and repeat revascularization (75.5 versus 83.9%, P < 0.001), but not death and MI. In the CABG group, no difference in outcomes was seen between incomplete and complete revascularization groups. Incomplete revascularization was identified as independent predictor of MACCE in PCI (HR = 1.55, 95% CI 1.15-2.08, P = 0.004) but not CABG patients. Independent predictors of incomplete revascularization by PCI were hyperlipidaemia (OR = 1.59, 95% CI 1.04-2.42, P = 0.031), a total occlusion (OR = 2.46, 95% CI 1.66-3.64, P < 0.001) and the number of vessels (OR = 1.58, 95% CI 1.41-1.77, P < 0.001). Independent predictors of incomplete revascularization by CABG were unstable angina (OR = 1.42, 95% CI 1.02-1.98, P = 0.038), diffuse disease or narrowed ( < 2 mm) segment distal to the lesion (OR = 1.87, 95% CI 1.31-2.69, P = 0.001) and the number of vessels (OR = 1.70, 95% CI 1.53-1.89, P < 0.001). Despite the hypothesis-generating nature of this data, this study demonstrates that incomplete revascularization is associated with adverse events during follow-up after PCI but not CABG.
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