A case-vignette based assessment of patient's perspective on coronary revascularization strategies, the OPINION study

A Partially Randomized Patient Preference Trial to Assess the Quality of Life and Patency Rate After Minimally Invasive Cardiac Surgery-Coronary Artery Bypass Grafting: Design and Rationale of the MICS-CABG PRPP Trial

Background

Minimally invasive cardiac surgery-coronary artery bypass grafting (MICS-CABG) has emerged as a safe alternative to standard cardiac surgery. However, treatment preferences can decrease the generalizability of RCT results to the clinical population (i.e., reduce external validity) and influence adherence to the treatment protocol and study outcomes (i.e., reduce internal validity). However, this has not yet been properly investigated in randomized trials with consideration of treatment preferences.

Study Design

In this study, patients with a preference will be allocated to treatment strategies accordingly, whereas only those patients without a distinct preference will be randomized. The randomized trial is a 248-patient controlled, randomized, investigator-blinded trial. It is designed to compare whether treatment with MICS-CABG is beneficial in comparison to CABG. This study is aimed to establish the superiority hypothesis for the physical component summary (PCS) accompanied by the non-inferiority hypothesis for overall graft patency. Patients with no treatment preference will be randomized in a 1:1 fashion to one of the two treatment arms. The primary efficacy endpoints are the PCS score at 30 days after surgery and the overall patency rate of the grafts within 14 days after surgery. Secondary outcome measures include the PCS score and patency rate at different time points. Safety endpoints include major adverse cardiac and cerebrovascular events, complications, bleeding, wound infection, death, etc.

Conclusions

This trial will address essential questions of the efficacy and safety of MICS-CABG. The study will also address the impact of patients' preferences on external validity and internal validity.

The Influence of Personality Type D on Cardiovascular Prognosis in Patients After Coronary Artery Bypass Grafting: Data from a 5-Year-Follow-up Study

BACKGROUND

Type D personality is accompanied by a set of negative behavioral patterns: low physical activity, high levels of psychological distress, low adherence to treatment. However, studies regarding predictive value of the type D personality remain inconclusive: the results varied depending on the examined cohort, age, and ethnicity. The aim of the study was to evaluate the influence of type D personality on the 5-year prognosis in patients undergoing coronary artery bypass grafting (CABG) in Russian population.

METHODS

The study included 602 patients with stable coronary artery disease (490 males, 57.7 ± 7.3 years) who had received CABG and were divided into two groups: patients with type D personality (n = 134) and patients without type D (n = 468). The risk of fatal and nonfatal events within 5 years after CABG was assessed.

RESULTS

There was no difference in total mortality in patients with type D and without type D (7.9% and 7.7%, respectively) over the 5-year period. The absence of cardiac events was detected much less frequently in patients with type D (28%) compared with patients without type D (82%; p = 0.021). Multivariate analysis found independent association between the unfavorable outcome and presence of diabetes mellitus (p = 0.021), type D personality (p = 0.039), and multifocal atherosclerosis (p = 0.033) regardless of gender, age, previous myocardial infarction, and stroke.

CONCLUSIONS

Type D patients had a greater risk for cardiac events over 5 years after CABG compared with non-type D patients. Obtained data indicates that it is reasonable to consider personality type while detecting patients at risk of development of stress induced cardiac complications after CABG.

Patient perspectives on left main stem revascularization strategies, the OPINION-2 study

BACKGROUND

Treatment preferences in patients with left main (LM) stem disease and no prior revascularization are unknown. The objectives of this study were to determine (i) patient-reported importance ratings of particular features related to percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery, (ii) how these features determine treatment preference, and (iii) how educational and psychosocial background influence this preference.

METHODS

In this prospective, multicenter study a total of 500 patients without previous revascularization who underwent diagnostic angiography for suspected coronary disease were asked to complete a case-vignette on a (hypothetical) LM stenosis qualifying for both PCI and CABG, in addition to 6 validated questionnaires to assess the influence of psychosocial factors on treatment preference.

RESULTS

Overall, 90% favored PCI over CABG because of the lower bleeding and stroke risk despite a higher likelihood for repeat revascularization. By multivariable regression, the only independent determinant of treatment preference for CABG was lower educational level (14% in low vs. 8% in higher educated patients, OR: 3.22, CI: 1.16-8.95, p=0.025) while psychosocial variables were not associated. Compared to higher educated patients, those with lower educational level suffered more from depression, anxiety, loneliness, and uncertainty.

CONCLUSIONS

Overall, patients who are informed about risk and benefits of each treatment modality clearly favor PCI over CABG and particularly value lower short-term morbidity while being aware of higher risk of repeat revascularization. Lower educational level was associated with a higher prevalence of psychosomatic phenotypes and a 14% preference for CABG. Educational and psychosocial background matter in the revascularization strategy decision-making process.