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Ram E, Fisman EZ, Tenenbaum A, Iakobishvili Z, Peled Y, Raanani E, Sternik L. Revascularization outcomes in diabetic patients presenting with acute coronary syndrome with non-ST elevation. Cardiovasc Diabetol 2022; 21:175. [PMID: 36064537 PMCID: PMC9443038 DOI: 10.1186/s12933-022-01595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 08/03/2022] [Indexed: 11/28/2022] Open
Abstract
Background To compare the outcomes of diabetic patients hospitalized with non-ST elevation myocardial infarction (NSTEMI) or unstable angina (UA) referred for revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in a real-life setting. Methods The study included 1987 patients with diabetes mellitus enrolled from the biennial Acute Coronary Syndrome Israeli Survey between 2000 and 2016, who were hospitalized for NSTEMI or UA, and underwent either PCI (N = 1652, 83%) or CABG (N = 335, 17%). Propensity score-matching analysis compared all-cause mortality in 200 pairs (1:1) who underwent revascularization by either PCI or CABG. Results Independent predictors for CABG referral included 3-vessel coronary artery disease (OR 4.9, 95% CI 3.6–6.8, p < 0.001), absence of on-site cardiac surgery (OR 1.4, 95% CI 1.1–1.9, p = 0.013), no previous PCI (OR 1.5, 95% CI 1.1–2.2, p = 0.024) or MI (OR 1.7, 95% CI 1.2–2.6, p = 0.002). While at 2 years of follow-up, survival analysis revealed no differences in mortality risk between the surgical and percutaneous revascularization groups (log-rank p = 0.996), after 2 years CABG was associated with a significant survival benefit (HR 1.53, 95% CI 1.07–2.21; p = 0.021). Comparison of the propensity score matching pairs also revealed a consistent long-term advantage toward CABG (log-rank p = 0.031). Conclusions In a real-life setting, revascularization by CABG of diabetic patients hospitalized with NSTEMI/UA is associated with better long-term outcomes. Prospective randomized studies are warranted in order to provide more effective recommendations in future guidelines. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01595-5.
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Affiliation(s)
- Eilon Ram
- Department of Cardiac Surgery, Tel Aviv University, Tel Aviv, Israel. .,Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel. .,The Sheba Talpiot Medical Leadership Program, Ramat Gan, Israel. .,Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.
| | - Enrique Z Fisman
- Department of Cardiac Surgery, Tel Aviv University, Tel Aviv, Israel.,Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Alexander Tenenbaum
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Zaza Iakobishvili
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel.,Clalit Health Services, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Peled
- Department of Cardiology, Tel Aviv University, Tel Aviv, Israel.,Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Ehud Raanani
- Department of Cardiac Surgery, Tel Aviv University, Tel Aviv, Israel.,Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, Tel Aviv University, Tel Aviv, Israel.,Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
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Meta-analysis comparing percutaneous coronary intervention with coronary artery bypass grafting for non-ST elevation acute coronary syndrome in patients with multivessel or left main disease. Curr Probl Cardiol 2022; 47:101306. [PMID: 35810843 DOI: 10.1016/j.cpcardiol.2022.101306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Outcomes of patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) with multivessel coronary disease (MVD) and/or unprotected left main coronary artery disease (CAD) revascularized with percutaneous coronary intervention(PCI) or coronary artery bypass grafting(CABG) is not well defined. DESIGN MEDLINE/PubMed and EMBASE/Ovid were queried for studies that investigated PCI vs. CABG in this disease subset. The primary outcome was major cardiac adverse events (MACE) at 30 days and long-term follow-up (3 to 5 years). RESULTS The final analysis included 9 studies with a total of 9299 patients. No significant difference was observed between PCI and CABGin30 days MACE (risk ratio [RR] 0.96; 95% confidence interval [CI] 0.38-2.39, all-cause mortality, myocardial infarction, and stroke. A meta-regression analysis revealed patients with a history of PCI had higher risk of MACE with PCI as compared with CABG. At long-term follow-up, PCI compared with CABG was associated with higher risk of MACE (RR 1.52; 95% CI 1.28-1.81), myocardial infarction, and repeat revascularization, while no difference was observed in the risk of stroke and all-cause mortality. CONCLUSION In patients with NSTE-ACS and MVD and/or unprotected left main CAD, no differences were observed in the clinical outcomes between PCI and CABG at 30 days follow-up. With long-term follow-up, PCI was associated with a higher risk of MACE.
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3
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Li T, Jiang L, Xu L, Tian J, Zhao X, Feng X, Wang D, Zhang Y, Sun K, Xu J, Liu R, Xu B, Zhao W, Hui R, Gao R, Song L, Yuan J. Interaction Between Treatment and Age or Sex in Non-ST-Segment Elevation Acute Coronary Disease and Three-Vessel Disease. Front Cardiovasc Med 2022; 9:879834. [PMID: 35722116 PMCID: PMC9200996 DOI: 10.3389/fcvm.2022.879834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/25/2022] [Indexed: 11/28/2022] Open
Abstract
Aims To explore the effects of age and sex on the outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients with the three-vessel disease (TVD). Methods and Results The study is a subanalysis of data from a prospective cohort of 8,943 patients with angiographically confirmed TVD at Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China. The primary end point was major adverse cardiac and cerebrovascular events (MACCEs), a composite of all-cause death, myocardial infarction, and stroke. In total, 2,819 patients with NSTE-ACS who received CABG (43.6%) or PCI (56.4%) were included, among whom 32.7% were of 65-74 years, 7.2% were ≥75 years, and 22.6% were women. The median follow-up duration was 6.8 years. The superiority of CABG relative to PCI in terms of MACCE was decreased with age (adjusted hazard ratio [HR] [95% confidence interval (CI)]: <65 years: 0.662 [0.495-0.885], p = 0.005; 65-74 years: 0.700 [0.512-0.956], p = 0.025; ≥75 years: 0.884 [0.529-1.479], p = 0.640) and was only seen in men (adjusted HR [95% CI]: men: 0.668 [0.526-0.848], p = 0.001; women: 0.713 [0.505-1.006], p = 0.054). Significant treatment-by-sex and treatment-by-age interactions were observed in patients ≥ 75 years and women, respectively, (p interaction with sex = 0.001; p interaction with age = 0.002). Conclusion Coronary artery bypass grafting is favorable for most NSTE-ACS patients with TVD. The preponderance of CABG over PCI disappeared in patients ≥ 75 years and women. PCI is superior in women ≥ 75 years.
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Affiliation(s)
- Tianyu Li
- National Clinical Research Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Jiang
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lianjun Xu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Tian
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xueyan Zhao
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinxing Feng
- Department of Endocrinology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Wang
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yin Zhang
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Sun
- Information Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingjing Xu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ru Liu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Zhao
- Information Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rutai Hui
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Runlin Gao
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Song
- National Clinical Research Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- National Clinical Research Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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A systematic review and meta-analysis of percutaneous coronary intervention compared to coronary artery bypass grafting in non-ST-elevation acute coronary syndrome. Sci Rep 2022; 12:5138. [PMID: 35332253 PMCID: PMC8948200 DOI: 10.1038/s41598-022-09158-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 03/17/2022] [Indexed: 02/05/2023] Open
Abstract
Non-ST-elevation acute coronary syndrome (NSTE-ACS) affects millions of patients. Although an invasive strategy can improve survival, the optimal treatment [i.e., percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)] is not clear. We performed a meta-analysis of studies reporting outcomes between PCI and CABG in patients with NSTE-ACS. MEDLINE, EMBASE and Cochrane Library were assessed. The primary outcome was long-term mortality. Inverse variance method and random model were performed. We identified 13 observational studies (48,891 patients). No significant difference was found in the primary endpoint [CABG vs. PCI, incidence rate ratio (IRR) 0.93, 95% confidence interval (CI) 0.70; 1.23]. CABG was associated with lower long-term major adverse cardiovascular events (MACE) (IRR 0.64, 95% CI 0.54; 0.76) and lower long-term re-revascularization (IRR 0.37, 95% CI 0.30; 0.47). There was no significant difference in long-term myocardial infarction (CABG vs. PCI, IRR 0.96, 95% CI 0.50; 1.84) and peri-operative mortality (CABG vs. PCI, odds ratio 1.36, 95% CI 0.94; 1.95). For the treatment of NSTE-ACS, CABG and PCI are associated with similar rates of long-term mortality and myocardial infarction. CABG is associated with lower rates of long-term MACE and re-revascularization. Randomized comparisons in this setting are necessary.
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Hamaya R, Chang YT, Chewcharat A, Chiu N, Yonetsu T, Kakuta T, Papatheodorou S. Comparison of invasive treatment strategies in patients with non-ST elevation acute coronary syndrome: A systematic review and meta-analysis. JTCVS OPEN 2021; 8:323-335. [PMID: 36004105 PMCID: PMC9390253 DOI: 10.1016/j.xjon.2021.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 08/20/2021] [Indexed: 11/24/2022]
Abstract
Objective To compare the mortality associated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with non-ST elevation acute coronary syndrome (NSTE-ACS). Methods We searched publications from PubMed, Embase, Web of Science, and the Cochrane Library from inception until December 23, 2020. All randomized clinical trials (RCTs) and observational studies comparing all-cause mortality after treatment with CABG versus PCI for patients with NSTE-ACS with minimum follow-up of 6 months were included. Restricted mean survival time (RMST) differences from RCTs and adjusted RMST differences from observational studies were computed by reconstructing time-to-event data from published Kaplan-Meier curves. Extracted hazard ratios (HRs) were also assessed as a secondary analysis. Results Our systematic review included an individual participant data analysis of 3 RCTs and 8 observational studies. A meta-regression showed a significant association between log-transformed HRs and duration of follow-up (-0.009 [95% confidence interval (CI), -0.002 to -0.016] log-HR per 1-year longer follow-up; P = .037), suggesting a violation of the proportional hazard assumption. Analysis of 6 studies with available RMST data showed a significant inverse association between adjusted RMST differences and cutoff years (slope, -0.028 [95% CI, -0.042 to -0.013] year difference per 1-year longer cutoff; P < .005), suggesting a longer survival benefit in the CABG arm compared with the PCI arm with longer follow-up. Conclusions There was a trend toward a benefit of CABG compared with PCI in the longer follow-up in patients with NSTE-ACS. A large, well-designed RCT with longer follow-up is needed to obtain definitive evidence on this topic.
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Affiliation(s)
- Rikuta Hamaya
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Mass
- Division of Preventive Medicine, Brigham and Women's Hospital, Boston, Mass
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuan Ting Chang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Mass
| | - Api Chewcharat
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Mass
| | - Nicholas Chiu
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Mass
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
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Outcomes of different revascularization strategies among patients presenting with acute coronary syndromes without ST elevation. J Thorac Cardiovasc Surg 2020; 160:926-935.e6. [DOI: 10.1016/j.jtcvs.2019.08.130] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/04/2019] [Accepted: 08/14/2019] [Indexed: 12/23/2022]
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7
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Long-term (10-year) outcomes of stenting or bypass surgery for acute coronary syndromes and stable ischemic heart disease with unprotected left main coronary artery disease. Am Heart J 2019; 218:9-19. [PMID: 31655415 DOI: 10.1016/j.ahj.2019.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/09/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acuity of clinical presentation may influence decision making of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease. However, it is undetermined whether clinical indication for myocardial revascularization may affect the relative long-term effect after PCI and CABG. METHODS In the MAIN-COMPARE study including 2,240 patients with LMCA disease treated with PCI (n = 1102) or CABG (n = 1138), we examined interaction between acuity of clinical presentation (acute coronary syndromes [ACS] or non-ACS) and revascularization strategy on 10-year outcomes. Primary outcome was a composite of all-cause death, Q-wave myocardial infarction, or stroke. Secondary outcomes were all-cause death or target vessel revascularization. RESULTS In overall patients, 1,603 patients (71.6%) presented with ACS and 637 patients (28.4%) presented with non-ACS. The 10-year adjusted risks for primary composite outcome were similar after PCI and CABG among patients who presented with non-ACS (hazard ratio [HR] 1.07; 95% CI 0.71-1.61) and those who presented with ACS (HR 1.00; 95% CI 0.81-1.24) (P for interaction = .29). The adjusted risks of death were also similar between 2 groups in non-ACS (HR 0.98; 95% CI 0.63-1.51) and ACS (HR 1.02; 95% CI 0.81-1.28) patients (P for interaction = .62). The adjusted risks of target vessel revascularization were consistently higher after PCI in non-ACS (HR 6.38; 95% CI 3.14-12.96) and ACS (HR 3.96; 95% CI 2.80-5.60) patients (P for interaction = .39). CONCLUSIONS In patients with LMCA disease, we have identified no significant interaction between the acuity of clinical indication and the relative treatment effect of PCI versus CABG on 10-year clinical outcomes.
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Doucet S, Jolicœur EM, Serruys PW, Ragosta M, Kron IL, Scholtz W, Börgermann J, Zhang Y, McAndrew T, Sabik JF, Kappetein AP, Stone GW. Outcomes of left main revascularization in patients with acute coronary syndromes and stable ischemic heart disease: Analysis from the EXCEL trial. Am Heart J 2019; 214:9-17. [PMID: 31150791 DOI: 10.1016/j.ahj.2019.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 04/25/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prompt revascularization is often required in acute coronary syndromes (ACS), whereas stable ischemic heart disease (SIHD) may allow for more measured procedural planning. Whether the acuity of presentation preferentially affects outcomes after coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with left main coronary artery disease (LMCAD) is unknown. We investigated whether the acuity of presentation discriminated patients who derived a differential benefit from PCI versus CABG in the randomized Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial. METHODS We used multivariable Cox models to assess the interaction between the acuity of presentation, type of revascularization and outcomes in patients with low or intermediate SYNTAX scores enrolled in EXCEL. RESULTS At baseline, 1151 patients (60.7%) presented with SIHD and 746 patients (39.3%) presented with an ACS. The acuity of presentation was not associated with the primary endpoint of all-cause death, MI, or stroke at 3 years (multivariable adjusted hazard ratio [HR] 0.94; 95% CI 0.70-1.26, P = .64). The primary endpoint rate was similar in patients assigned to PCI versus CABG whether they presented with SIHD (adjusted HR 1.04; 95% CI 0.73-1.48]) or with ACS (HR 0.82; 95% CI 0.54-1.26) (Pinteraction = .34). CONCLUSIONS The acuity of presentation did not predict outcomes in patients with LMCAD undergoing revascularization, nor did it discriminate patients who derive greater event-free survival from PCI versus CABG.
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Affiliation(s)
- Serge Doucet
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Canada
| | - E Marc Jolicœur
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Canada
| | - Patrick W Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom
| | | | - Irving L Kron
- University of Virginia Health System, Charlottesville, VA
| | - Werner Scholtz
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Jochen Börgermann
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Yiran Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, OH
| | | | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY; Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY.
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Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients With Non-ST-Elevation Myocardial Infarction and Left Main or Multivessel Coronary Disease. Am J Cardiol 2019; 123:717-724. [PMID: 30558758 DOI: 10.1016/j.amjcard.2018.11.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 11/10/2018] [Accepted: 11/16/2018] [Indexed: 11/22/2022]
Abstract
Current recommendations on the optimal revascularization strategy in Non-ST-elevation myocardial infarction (NSTEMI) with left main (LM) or multivessel coronary disease (MVD) are based upon randomized clinical trials conducted in stable coronary artery disease. In a real-world contemporary observational registry, we compared the long-term outcome of NSTEMI patients with LM/MVD (n = 1,104) submitted to coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimized medical therapy (OMT). The primary end point was 5-year all-cause mortality. Results were assessed in the entire population (CABG 289, PCI 399, and OMT 416) and in a propensity score-matched cohort of CABG (n = 159) and PCI (n = 159). Crude 5-year mortality rates in CABG and PCI were 25.3% versus 29.6%, respectively (unadjusted hazard ratio [HR] 1.2; 95% confidence intervals [CI] 0.9 to 1.6; p = 0.212); OMT, however, was associated with a twofold higher risk of mortality when compared with any revascularization strategy (unadjusted HR 2.0; 95% CI 1.7 to 2.5; p < 0.001). After propensity score-matching and multivariate analysis, there was a trend toward a higher incidence of the primary end point in patients who underwent PCI versus CABG (31% vs 21%; adjusted HR 1.52; 95% CI 0.93 to 2.50; p = 0.094). This was a consistent finding over subgroups deemed clinically relevant, such as in patients with LM or proximal left anterior descending disease, SYNergy between percutaneous coronary intervention with TAXus ≥23 and left ventricle ejection fraction <40%. In conclusion, in a real-world cohort of NSTEMI patients with LM/MVD, those selected for OMT had a dire outcome. Although adjusted 5-year mortality was statistically similar between revascularization strategies, there was a trend favoring CABG, which might be the preferred option in LM, proximal LAD, SYNergy between percutaneous coronary intervention with TAXus ≥23, and left ventricle ejection fraction <40% subgroups.
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10
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Hong SJ, Kim BK, Shin S, Suh Y, Kim S, Ahn CM, Kim JS, Ko YG, Choi D, Hong MK, Jang Y. Determinants and Long-Term Outcomes of Percutaneous Coronary Interventions vs. Surgery for Multivessel Disease According to Clinical Presentation. Circ J 2018; 82:1092-1100. [PMID: 29434090 DOI: 10.1253/circj.cj-17-1173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The long-term outcome of percutaneous coronary intervention (PCI) vs. coronary artery bypass graft (CABG), particularly for patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), remains controversial.Methods and Results:We retrospectively analyzed 2,827 patients (stable coronary artery disease [SCAD], n=1,601; NSTE-ACS, n=1,226) who underwent either PCI (n=1,732) or CABG (n=1,095). The 8-year composite of cardiac death and myocardial infarction (MI) was compared between PCI and CABG before and after propensity matching. For patients with NSTE-ACS, PCI was performed more frequently for those with higher Thrombolysis in Myocardial Infarction risk score and 3-vessel disease, and PCI led to significantly higher 8-year composite of cardiac death and MI than CABG (14.1% vs. 5.9%, hazard ratio [HR]=2.22, 95% confidence interval [CI]=1.37-3.58, P=0.001). There was a significant interaction between clinical presentation and revascularization strategy (P-interaction=0.001). However, after matching, the benefit of CABG vs. PCI was attenuated in patients with NSTE-ACS, whereas it was pronounced in those with SCAD. Interactions between clinical presentation and revascularization strategy were not observed (P-interaction=0.574). CONCLUSIONS Although the determinants of PCI vs. CABG in real-world clinical practice differ according to the clinical presentation, a significant interaction between clinical presentation and revascularization strategy was not noted for long-term outcomes. The revascularization strategy for patients with NSTE-ACS can be based on the criteria applied to patients with SCAD.
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Affiliation(s)
- Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Sanghoon Shin
- Division of Cardiology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital
| | - Yongsung Suh
- Division of Cardiology, Department of Internal Medicine, Myongji Hospital
| | - Seunghwan Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
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11
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Desperak P, Hawranek M, Gąsior P, Desperak A, Lekston A, Gąsior M. Long-term outcomes of patients with multivessel coronary artery disease presenting non-ST-segment elevation acute coronary syndromes. Cardiol J 2017; 26:157-168. [PMID: 28980282 DOI: 10.5603/cj.a2017.0110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/10/2017] [Accepted: 09/10/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There is paucity of data concerning the optimal revascularization in patients with mul- tivessel coronary artery disease (CAD) presenting non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The aim was to evaluate long-term outcomes of patients with multivessel CAD presenting NSTE-ACS depending on the management after coronary angiography. METHODS 3,166 patients with NSTE-ACS hospitalized between 2006 and 2014 were screened. After ex- clusions, 1,342 patients were enrolled with multivessel CAD and were divided depending on their man- agement after coronary angiography; the medical-only therapy group (n = 91), the percutaneous coronary intervention (PCI) group (n = 1,122), the coronary artery bypass grafting (CABG) group (n = 129). Propensity scores matching was used to adjust for differences in patient baseline characteristics. RESULTS After propensity score analysis, 273 well-matched patients were chosen. Both before and after matching, patients treated with a medical-only therapy were burdened with the highest percentage of 24-month all-cause death and non-fatal MI in comparison to PCI and CABG groups, respectively. In the CABG group, ACS-driven revascularization rate was lowest. In the overall population, PCI (HR 0.33; 95% CI 0.20-0.53; p < 0.0001) and CABG (HR 0.54; 95% CI 0.31-0.93; p = 0.028) were independent factors associated with favorable 24-month prognosis. However, in a matched population only PCI was an independent predictor of long-term prognosis with a 63% decrease of 24-month mortal- ity (HR 0.37; 95% CI 0.19-0.69; p = 0.0020). CONCLUSIONS In patients with multivessel CAD presenting with NSTE-ACS, medical-only man- agement is related with adverse long-term prognosis in contrast to revascularization, which reduces 24-month mortality, especially among patients undergoing percutaneous intervention. Performance of PCI is an independent factor for improving long-term prognosis.
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Affiliation(s)
- Piotr Desperak
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland.
| | - Michał Hawranek
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Paweł Gąsior
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, Katowice, Poland
| | - Aneta Desperak
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Andrzej Lekston
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Mariusz Gąsior
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
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Khan AR, Golwala H, Tripathi A, Riaz H, Kumar A, Flaherty MP, Bhatt DL. Meta-analysis of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Left Main Coronary Artery Disease. Am J Cardiol 2017; 119:1949-1956. [PMID: 28442067 DOI: 10.1016/j.amjcard.2017.03.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 02/06/2023]
Abstract
Despite the increase in use of percutaneous coronary intervention (PCI) in left main coronary disease, its efficacy compared with coronary artery bypass grafting (CABG) is unclear. We performed a meta-analysis of randomized controlled trials to assess the optimal revascularization strategy. Our search yielded 8 studies reporting relevant outcomes that were pooled using the inverse variance method, and the hazard ratio (HR) was calculated. The primary outcome was all-cause mortality, myocardial infarction (MI), or stroke (major adverse cardiac events [MACE]), and the secondary outcome was death/MI/stroke/repeat revascularization (expanded MACE). Differences in outcomes classified by follow-up duration (early: 0 to 1 year; late: 3 to 5 years) or anatomical complexity of coronary artery disease (SYNTAX score) were investigated. Our results suggest no difference in either early or late MACE (early: HR 0.81; 95% confidence interval [CI] 0.63 to 1.05; late: HR 1.12; 95% CI 0.80 to 1.56) or expanded MACE (early: HR 1.03; 95% CI 0.69 to 1.52; late: HR 1.16; 95% CI 0.95 to 1.43) between the 2 groups. There was an increased risk of expanded MACE with a high SYNTAX score for PCI (HR 1.47; 95% CI 1.13 to 1.92) at late follow-up. There were comparable rates of all-cause mortality and nonprocedural MI between the 2 groups with increased rates of repeat revascularization with PCI throughout the follow-up and higher rates of stroke with coronary artery bypass grafting early in the follow-up period. In conclusion, our analysis suggests that CABG may be preferable in patients with left main disease and high SYNTAX scores, assuming they are at low surgical risk, and PCI may be an acceptable alternative in patients with low-intermediate SYNTAX scores.
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Rankin JS. Invited commentary. Ann Thorac Surg 2015; 99:574-5. [PMID: 25639398 DOI: 10.1016/j.athoracsur.2014.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 10/23/2014] [Accepted: 10/31/2014] [Indexed: 11/25/2022]
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