Long-term mortality of coronary artery bypass grafting and bare-metal stenting

Trauma Recidivism Predicts Long-term Mortality: Missed Opportunities for Prevention (Retrospective Cohort Study)

OBJECTIVES

The objectives of this study were to determine the association between recurrent trauma admissions (recidivism) and subsequent long-term mortality, and to identify those in most need for preventive interventions.

BACKGROUND

Patients with a single intentional injury have been shown to have a higher risk of future injury mortality than those with unintentional injury with 5-year mortality rates as high as 20% being reported for recurrent penetrating trauma. Trauma recidivism identifies a high-risk population, but its association with long-term mortality is largely unknown.

METHODS

Patients with 1 or more previous admissions to an urban trauma center (recidivists) were identified and compared with those with single admissions (nonrecidivists) from 1997 to 2008. The trauma registry was linked to the National Death Index to determine both the cause and time to death after hospital discharge. Statistical analysis included chi-square tests, Kaplan-Meier survival curves, and Cox proportional-hazards models.

RESULTS

Trauma recidivists were 7% of the total trauma population from 1997 to 2008, representing 3147 patients. Recidivists were more likely to be male (P < 0.0001), Black (P < 0.0001), have a blood alcohol content above 80 mg/dL (P < 0.0001), and suffer a penetrating injury (P < 0.0001) compared with nonrecidivists. Recidivists with both initial blunt and penetrating injuries had higher rates of long-term mortality after discharge. Recidivists were more likely to die of any cause based on Cox proportional-hazard ratios [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.57-2.01], injury death (HR 2.02, 95% CI 1.66-2.47), and disease death (HR 1.65, 95% CI 1.41-1.92) than nonrecidivists.

CONCLUSIONS

Male sex, Black race, and elevated blood alcohol content and penetrating injury are associated with trauma recidivism which leads to a higher risk of death. There is a critical public health need to develop interventions to reduce trauma recidivism and preventable death.

Regional differences in coronary revascularization procedures and outcomes: a nationwide 11-year observational study

Aims

The study investigated whether regional differences in choice of coronary revascularization affected outcomes in Sweden.

Methods and results

We conducted a prospective nationwide study of outcome in patients undergoing coronary artery bypass grafting (CABG, n = 47 065) or percutaneous coronary intervention (PCI, n = 140 945) from 2001 through 2011, tracked for a median of 5 years. During this period, the proportion of CABG in revascularization procedures decreased nationwide from an average of 38% to 18%e. Three-vessel disease and left main stem coronary artery stenosis were more common among CABG patients than in PCI patients. In both males and females, all-cause mortality was higher in CABG patients than in PCI patients, while repeat PCI was performed more frequently in the PCI group. CABG proportions in 21 counties ranged from 13% to 42% in females and males. The combined outcomes of repeat revascularization, non-fatal acute myocardial infarction, and death during the tracking period was recorded in 151 936 patients without ST-elevation myocardial infarction after PCI (n = 37 820, 36%) and CABG (n = 18 903, 40%). The multivariable adjusted risk of combined outcomes was higher after both PCI and CABG in both females and males in the three quartiles of counties with a smaller proportion of CABG than in the quartile of counties with the highest proportion of CABG. Similar patterns persisted after including only mortality in the analyses.

Conclusion

There are subgroups of patients who have prognostic benefits of CABG in addition to symptomatic improvement that is well documented with both PCI and CABG.

Outcomes of trauma admission for falls: influence of race and age on inhospital and post-discharge mortality

BACKGROUND

Racial disparities in trauma outcomes occur, but disparities in fall mortality are unknown. The objective of this study was to determine inhospital and 1-year fall mortality among patients discharged from an urban trauma center.

METHODS

We conducted a retrospective analysis of fall patients in our trauma registry (1997 to 2008) linked to the National Death Index to determine postdischarge mortality. Statistical analysis included chi-square tests, multivariable logistic regression, and Cox proportional hazards models.

RESULTS

There were 7,541 fall admissions. There was no clinically significant difference in inhospital mortality between blacks and whites with age stratification. One year after discharge, blacks younger than 65 years were more likely to die of disease (hazard ratio, 1.37; 95% confidence interval, 1.14 to 1.62).

CONCLUSIONS

Although rates of inhospital mortality are similar, blacks younger than 65 years have a higher risk of dying after discharge due to disease when stratified by age highlighting the need for continued medical follow-up and prevention efforts.

Association between intentional injury and long-term survival after trauma

OBJECTIVE

To determine the risk-adjusted mortality of intentionally injured patients within 7 to 9 years postinjury, compared with unintentionally injured patients.

BACKGROUND

Violent injury contributes significantly to trauma mortality in the United States. Homicide is the second leading killer of American youth, aged 15 to 24 years. Long-term survival among intentionally injured patients has not been well studied. It is also unknown whether intentionally injured patients have worse long-term survival compared with unintentionally or accidentally injured patients with equivalent injuries.

METHODS

Adult trauma patients admitted for 24 hours or more and discharged alive from the Johns Hopkins Hospital from January 1, 1998, to December 31, 2000, were included. The primary outcome was mortality within 7 to 9 years postinjury. Long-term patient survival was determined using the National Death Index. The association between injury intentionality and mortality was investigated using a Cox proportional hazard regression model, adjusted for confounders such as injury severity and patient race, socioeconomic status, and comorbid conditions. Overall differences in survival between those with intentional versus unintentional injury were also determined by comparing adjusted Kaplan-Meier survival curves.

RESULTS

A total of 2062 patients met inclusion criteria. Of these, 56.4% were intentionally injured and 43.6% were unintentionally injured. Compared with unintentionally injured patients, intentionally injured patients were younger and more often male and from a zip code with low median household income. Approximately 15% of all patients had died within 7 to 9 years of follow-up. Older age and presence of comorbidities were associated with this outcome; however, intentional injury was not found to be significantly associated with long-term mortality rates. There was also no significant difference in survival curves between groups; intentionally injured patients were much more likely to die of a subsequent injury, whereas those with unintentional injury commonly died of noninjury causes.

CONCLUSIONS

There was no significant difference in mortality between intentionally injured and unintentionally injured patients within 7 to 9 years postinjury. These results confirm the long-term effectiveness of lifesaving trauma care for those with intentional injury. However, given that patients with intentional injuries were more likely to suffer a subsequent violent death, interventions focused on breaking the cycle of violence are needed.

Stents or surgery in coronary artery disease in 2013

In addition to optimal medical therapy, some patients with coronary artery disease also require intervention on symptomatic and/or prognostic grounds. The debate over the relative efficacies of coronary artery bypass grafting (CABG) and stenting has recently been settled by the publication of the five-year outcomes of the SYNTAX and FREEDOM (in patients with diabetes) trials accompanied by supportive data from several large registries. There is also current evidence that stenting is still carried out in patients who would be better served by CABG, emphasizing the need for recommendations for intervention to be overseen by a multidisciplinary team rather than the individual practitioner.

Coronary artery revascularization evaluation--a multicenter registry with seven years of follow-up

Background

Data from randomized clinical trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) may not accurately reflect current clinical practice, in which there is off‐label usage of drug‐eluting stents (DES). We undertook a prospective registry of coronary revascularization by CABG on‐ and off‐pump and PCI with bare‐metal stents (BMSs), DESs, or percutaneous transluminal coronary angioplasty (PTCA) to determine clinical outcomes.

Methods and Results

All patients undergoing isolated coronary revascularization in 8 community‐based hospitals were enrolled. Final follow‐up was obtained after 5 years by patient and/or physician contact and the Social Security Death Index. ST‐elevation myocardial infarction and salvage patients were excluded. Five or more years of follow‐up was obtained on 81.5% (3156) of the eligible patients—968 CABG patients (82.0%) and 2188 PCI patients (81.3%). Overall follow‐up was 63.5±27.9 months (median, 79.7 months). The incidence of initial major adverse cardiac events (MACEs) at follow‐up for CABG versus PCI was 29.2% versus 41.8% (P<0.001). Analysis of stent subgroups showed more events with BMSs (equivalent to PTCA alone) compared with DESs. All stents had more events than on‐ or off‐pump CABG groups. Using propensity score–matched groups, the odds ratio for CABG to PCI was 0.69 (95% confidence interval [CI], 0.56 to 0.85; P<0.001) for mortality and 0.58 (95% CI, 0.45 to 0.75; P<0.001) for any MACE.

Conclusions

In the current era of DES and off‐pump surgery, in a community hospital setting, comparable patients undergoing coronary revascularization appear to benefit from improved long‐term survival and reduced MACE with CABG versus PCI.

Long-term mortality of coronary artery bypass graft surgery and stenting with drug-eluting stents

BACKGROUND

Few studies have examined differences in long-term mortality between coronary artery bypass graft surgery and stenting with drug-eluting stents (DES) for multivessel disease without left main coronary artery stenosis. This study compares the risks of long-term mortality between these 2 procedures during a follow-up of up to 5 years.

METHODS

Patients who underwent isolated bypass surgery (n=13,212) and stenting with DES (n=20,161) between October 2003 and December 2005 in New York State were followed for their vital status through 2008. To control for treatment selection bias, bypass and stenting patients were matched on age, number of diseased coronary vessels, presence of proximal or nonproximal left anterior descending (LAD) artery disease, and propensity of undergoing bypass surgery. Five-year survival rates for the 2 procedures were compared and hazard ratios for death of bypass surgery compared with stenting were obtained.

RESULTS

The respective 5-year survival rates in the 8,121 pairs of matched bypass and stenting patients were 80.4% and 73.6% (p<0.001), and the risk of death after bypass surgery was 29% lower than for stenting (hazard ratio = 0.71, 95% confidence interval: 0.67 to 0.77, p<0.001). Significantly lower risks of death for bypass surgery were observed in patients with LAD artery disease but not in patients without LAD artery disease. Significantly lower risks of death for bypass surgery were also found in all patient subgroups defined by the presence of selected baseline risk factors.

CONCLUSIONS

Bypass surgery is associated with lower risk of death than stenting with DES for multivessel disease without left main stenosis.

Long-Term Mortality of 306,868 Patients with Multi-Vessel Coronary Artery Disease: CABG versus PCI

Background

Several randomized controlled trials (RCT) have reported no difference in long-term mortality between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). The purpose of this pooled observational analysis was to compare recent retrospective studies examining long-term survival of patients with multi-vessel coronary artery disease undergoing CABG and PCI.

Methodology

We searched Medline for observational studies comparing long-term (>1 year) survival between CABG and PCI for the treatment of multi-vessel coronary artery disease over the past 10 years.

Results

Eight studies met inclusion criteria. A total of 306,868 patients (155,502 CABG; 151,366 PCI) were identified. Follow-up ranged from 1 to 8 years. Mantel-Haenszel combined hazard ratios (HR) for mortality demonstrated a protective benefit of CABG compared with PCI (HR=0.77, 95%CI=0.75–0.79).

Conclusion

These findings suggest a long-term survival advantage for CABG compared with PCI in patients with multi-vessel coronary artery disease.

Arterial grafts protect the native coronary vessels from atherosclerotic disease progression

BACKGROUND

We sought to examine the effect of different conduits on the progression of atherosclerosis in previously revascularized coronary territories.

METHODS

Between 1995 and 2010, 4,960 patients were discharged alive after primary isolated coronary artery bypass grafting (CABG) with a left internal thoracic artery (LITA) conduit and additional conduits as needed: radial artery (RA) or saphenous vein graft (SVG), or both. Seven hundred seventy-two patients had coronary angiography for recurrent symptoms an average of 5.5±3.5 years after CABG (range, 0.1-16 years). Cumulative graft patency and disease progression in the native vessels was estimated by the Kaplan-Meier survival method. The log-rank test was used to assess differences of disease progression per territory between different types of conduits.

RESULTS

Kaplan-Meier-estimated 1-, 5-, and 10-year overall disease progression in territories with patent LITAs was 0.01%, 4%, and 8%, respectively; with patent RA grafts, it was 0.01%, 6%, and 11%, respectively (log-rank test, p=0.157); and with patent SVGs it was 3%, 19%, and 43%, respectively (log-rank test; p<0.0001). Disease progression in grafted native coronary arteries in the anterior territory with patent LITA-to-left anterior descending (LAD) artery was 8%, and with patent RA grafts versus patent SVGs to the diagonal branches of LAD artery was 10% and 40%, respectively (log-rank test; p<0.0001). Disease progression in grafted native coronary arteries to the lateral territory with a patent RA graft was 11% versus 50% with a patent SVG (log-rank test; p<0.0001).

CONCLUSIONS

RA and LITA grafting has a strong protective effect against progression of native coronary artery disease in previously grafted vessels. Multiple arterial grafting may improve long-term survival by preventing progression of atherosclerosis in the native coronary vessels.

Completeness of revascularization and survival among octogenarians with triple-vessel disease

BACKGROUND

We sought to determine the impact of the completeness of surgical revascularization among octogenarians with triple-vessel disease.

METHODS

Between 1992 and 2008, 476 consecutive patients aged 80 years or more who underwent primary isolated coronary artery bypass grafting (CABG) procedures were identified. Early and late survival were compared among patients who underwent complete revascularization (CR, n=391) and incomplete revascularization (IR, n=85). IR was present when 1 or more of the 3 main coronary arteries with 50% or greater stenosis that were identified preoperatively as a surgical target by the operating surgeon were not grafted. The mean follow-up was 5.4±3.0 years (maximum 15.3 years).

RESULTS

Baseline risk was similar between the 2 groups of patients. IR was more frequent in off-pump compared with on-pump CABG (34.9% versus 16.2%, respectively; p=0.002). The most common reason for IR was small or severely diseased arteries (87%). The incidence of postoperative myocardial infarction (MI) was similar in both groups (CR, 18.4% versus IR, 17.3%; p=0.81). In-hospital mortality was 7.2% among patients with CR and 4.7% among patients with IR (p=0.60). Three, 5-, and 8-year freedom from all-cause mortality among patients who underwent CR were 89.2%, 74.1%, and 54.3%, respectively, and were not significantly different from those patients who underwent IR (86.6%, 74.5%, and 49.4%, respectively) (p=0.40).

CONCLUSIONS

In octogenarians with triple-vessel disease, a strategy of incomplete revascularization during CABG does not negatively impact early or long-term survival.

CABG in 2012: Evidence, practice and the evolution of guidelines

Abstract: In the management of coronary artery disease (CAD) it is important to ensure that all patients are receiving optimal medical therapy irrespective of whether any intervention, by stents or surgery, is planned. Furthermore it is important to establish if a proposed intervention is for symptomatic and/or prognostic reasons. The latter can only be justified if there is demonstration of a significant volume of ischaemia (>10% of myocardial mass). Taking together evidence from the most definitive randomized trial and its registry component (SYNTAX), almost 79% of patients with three vessel CAD and almost two thirds of patients with LMS disease have a survival benefit and marked reduction in the need for repeat revascularisation with CABG in comparison to stents, implying that CABG is still the treatment of choice for most of these patients. This conclusion which is apparently at odds with the results of most previous trials of stenting and surgery but entirely consistent with the findings of large propensity matched registries can be explained by the fact that SYNTAX enrolled ‘real life’ patients rather than the highly select patients usually enrolled in previous trials. SYNTAX also shows that for patients with less severe coronary artery disease there is no difference in survival between CABG and stents but a lower incidence of repeat revascularisation with CABG. At three years, SYNTAX shows no difference in stroke between CABG and stents for three-vessel disease but a higher incidence of stroke with CABG in patients with left main stem disease. In contrast the PRECOMBAT trial of stents and CABG in patients with left main stem disease showed no excess of mortality or stroke with CABG in comparison to stents in relatively low risk patients. Finally the importance of guidelines and multidisciplinary/heart teams in making recommendations for interventions is emphasised.