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Goulden CJ. Percutaneous coronary intervention versus coronary artery by-pass grafting in premature coronary artery disease: What is the evidence? -A narrative review. Perfusion 2025; 40:20-35. [PMID: 38108274 DOI: 10.1177/02676591231223356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Coronary artery disease (CAD) remains one of the leading causes of death globally. In the United States of America, in 2016, 19% of all patients under the age of 65 died of cardiovascular disease despite improvements in primary prevention. The premature clinical onset of symptoms in the young population (<60 years) is much more aggressive than in the older population, and the overall long-term prognosis is poor. CAD appears to have a rapidly progressive form in those under the age of 60 due to genetic predisposition, smoking, and substance abuse, however, the ideal management strategy is still yet to be established. The two primary methods of establishing coronary revascularization are percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Despite the increasing prevalence of CAD in the young population, they are consistently underrepresented in major randomized clinical trials of each revascularization strategy. Both CABG and PCI are known to have similar survival rates, but PCI is associated with higher repeat revascularization rate. Many argue this may be due to the progressive nature of CAD combined with the vessel patency time required in a patient under 60 with potentially another 20-30 years of life. There is little in literature regarding the outcomes of these various revascularization strategies in populations under 60 years with CAD. This review summarises the current evidence for each revascularisation strategy in patients under the age of 60 and suggests future avenues of research for this unique age group.
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Custódio P, Garcez L, Madeira S, Magro P, Vale N, Madeira M, Leal S, Nolasco T, Brito J, Boshoff S, De Araújo Gonçalves P, Marques M, Mesquita Gabriel H, Calquinha J, Campante Teles R, Abecasis M, Almeida M, Sousa Uva M, Mendes M, Pedro Neves J, Raposo L. Long-term health outcomes of young patients with low-complexity coronary disease: a weighted analysis according to revascularization strategy. Eur J Cardiothorac Surg 2024; 66:ezae367. [PMID: 39374540 DOI: 10.1093/ejcts/ezae367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 09/16/2024] [Accepted: 10/03/2024] [Indexed: 10/09/2024] Open
Abstract
OBJECTIVES Age is an important factor weighing on revascularization decisions. We analysed long-term health outcomes of young patients with low-complexity coronary anatomy suitable for both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), according to revascularization strategy. METHODS Patients 60 years old or less, undergoing invasive coronary angiography between January 2007 and December 2015, presenting with proximal left anterior descending artery involvement, left main or multivessel disease and a SYNTAX Score ≤22 were retrospectively selected. An inverse probability of treatment weight methodology generated a pseudopopulation with well-balanced characteristics, which was used to estimate the average treatment effect between PCI (n = 374) and CABG (n = 173). RESULTS Mean age was 53 ± 7 years old, 27% had diabetes mellitus and 48% presented with an acute coronary syndrome. Mean SYNTAX score was 13.6 ± 4.9 and 68% underwent PCI as index revascularization strategy. In the weighed population, the adjusted hazard of the primary end-point of all-cause death at total follow-up (median 9.3 years; interquartile range 6.9-11.7) was 0.40 (95% confidence interval 0.19-0.7) for CABG vs PCI (incidence rate 5.8 vs 14.0 deaths/1000-person-years). Accounting for death as competing risk, the cumulative hazard of new revascularization (sub-distribution hazard ratio 0.72; 95% confidence interval 0.32-1.25) and any cause hospital readmission (sub-distribution hazard ratio 0.70; 95% confidence interval 0.41-1.07) were lower in CABG patients, as opposed to death/stroke rates at 30 days which were higher with CABG (0.3% vs 1.7%; risk ratio = 5.84). CONCLUSIONS In this quasi-experimental analysis of young patients with coronary artery disease and an equivalent indication for both PCI and CABG, long-term health outcomes were favourably associated with CABG, as compared to PCI. These observations support the need for dedicated randomized trials with longer follow-up in order to better inform lifetime treatment options.
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Affiliation(s)
- Pedro Custódio
- Serviço de Cardiologia, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
| | - Luís Garcez
- CEAUL-Centro de Estatística e Aplicações, Faculdade de Ciências, Universidade de Lisboa, Lisbon, Portugal
| | - Sérgio Madeira
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Pedro Magro
- Serviço de Cirurgia Cardíaca, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Nelson Vale
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Márcio Madeira
- Serviço de Cirurgia Cardíaca, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Sílvio Leal
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Tiago Nolasco
- Serviço de Cirurgia Cardíaca, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - João Brito
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Sérgio Boshoff
- Serviço de Cirurgia Cardíaca, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Pedro De Araújo Gonçalves
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Marta Marques
- Serviço de Cirurgia Cardíaca, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Henrique Mesquita Gabriel
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - João Calquinha
- Serviço de Cirurgia Cardíaca, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Rui Campante Teles
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Miguel Abecasis
- Serviço de Cirurgia Cardíaca, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Manuel Almeida
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Miguel Sousa Uva
- Serviço de Cirurgia Cardíaca, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular R&D Centre-UnIC@RISE, University of Porto, Porto, Portugal
| | - Miguel Mendes
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - José Pedro Neves
- Serviço de Cirurgia Cardíaca, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Luís Raposo
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
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Alexim GDA, Rocha LF, Dobri GP, Rosa Júnior ADS, Reis RTB, Nogueira ACC, Soares AADSM, Sposito AC, de Paula AP, de Carvalho LSF. Clinical and economic impact of coronary artery bypass graft and percutaneous coronary intervention in young individuals with acute coronary syndromes and multivessel disease: A real-world comparison in a middle-income country. Front Cardiovasc Med 2022; 9:1000260. [PMID: 36440021 PMCID: PMC9685999 DOI: 10.3389/fcvm.2022.1000260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/17/2022] [Indexed: 08/22/2024] Open
Abstract
BACKGROUND In recent decades, the world watched a dramatic increase in the incidence of acute coronary syndromes (ACS) among young individuals (≤55 years-old) and a relative decrease in the elderly. The management of ACS in young patients with multivessel disease still needs to be elucidated, as these individuals maintain a long life expectancy. RESEARCH QUESTION To compare clinical outcomes and care costs in individuals with premature ACS and multivessel disease undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). METHODS AND RESULTS Participants included all individuals ≤55 years-old admitted with ACS to public hospitals in Brasília (Brazil) between 2013 and 2015 and who underwent cardiac catheterization with SYNTAX score ≥23 or Duke category 6. Outcomes were adjudicated with death certificates and data from medical records. The primary outcome was the occurrence of major adverse cardiovascular events (MACE), defined as death due to cardiovascular causes, recurrent hospitalizations due to cardiovascular ischemic events, and incident heart failure New York Heart Association III-IV. As secondary outcome we assessed indirect and direct costs by evaluating the cost of lost productivity (in international dollars (Int$) per year) due to illness and death, outpatient costs and costs with new hospitalizations. Multivariate and principal components (PC) adjusted analyzes were performed. RESULTS Among 1,088 subjects (111 CABG and 977 PCI) followed for 6.2 years (IQR: 1.1), 304 primary events were observed. MACE was observed in 20.7% of the CABG group and 28.8% of the PCI group (p = 0.037). In multivariate analyses, PCI was associated with a hazard ratio (HR) = 1.227 (95% CI: 1.004-1.499; p = 0.0457) for MACE, and in PC-adjusted HR = 1.268 (95% CI: 1.048-1.548; p = 0.0271) compared with CABG. Despite direct costs were equivalent, the cost due to the loss of labor productivity was higher in the PCI group (Int$ 4,511 (IQR: 18,062)/year vs Int$ 3,578 (IQR: 13,198)/year; p = 0.049], compared with CABG. CONCLUSIONS Among young individuals with ACS and multivessel disease, surgical strategy was associated with a lower occurrence of MACE and lower indirect costs in the long-term.
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Affiliation(s)
- Gustavo de Almeida Alexim
- Medical Sciences Post-Graduation Program, Escola Superior de Ciências da Saúde, Brasília, DF, Brazil
- Medical Sciences Post-Graduation Program, University of Brasília, Brasília, DF, Brazil
- Secretaria de Estado de Saúde do Distrito Federal (SES-DF), Brasília, DF, Brazil
| | - Luiza Ferreira Rocha
- Secretaria de Estado de Saúde do Distrito Federal (SES-DF), Brasília, DF, Brazil
- Instituto de Cardiologia e Transplantes do Distrito Federal, Brasília, DF, Brazil
| | - Giovani Prediger Dobri
- Secretaria de Estado de Saúde do Distrito Federal (SES-DF), Brasília, DF, Brazil
- Instituto de Cardiologia e Transplantes do Distrito Federal, Brasília, DF, Brazil
| | | | | | - Ana Claudia Cavalcante Nogueira
- Medical Sciences Post-Graduation Program, University of Brasília, Brasília, DF, Brazil
- Secretaria de Estado de Saúde do Distrito Federal (SES-DF), Brasília, DF, Brazil
- Aramari Apo Institute, Brasília, DF, Brazil
| | | | - Andrei Carvalho Sposito
- Aramari Apo Institute, Brasília, DF, Brazil
- Department of Cardiology, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Ana Patricia de Paula
- Medical Sciences Post-Graduation Program, Escola Superior de Ciências da Saúde, Brasília, DF, Brazil
| | - Luiz Sérgio Fernandes de Carvalho
- Medical Sciences Post-Graduation Program, Escola Superior de Ciências da Saúde, Brasília, DF, Brazil
- Medical Sciences Post-Graduation Program, University of Brasília, Brasília, DF, Brazil
- Aramari Apo Institute, Brasília, DF, Brazil
- Laboratory of Data for Quality of Care and Outcomes Research, Clarity Healthcare Intelligence, Jundiaí, SP, Brazil
- Gerontology Post-Graduation Program, Universidade Católica de Brasília, Brasília, DF, Brazil
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Coronary Revascularization for Patients with Diabetes Mellitus: A Contemporary Systematic Review and Meta-Analysis. Ann Surg 2022; 275:1058-1066. [PMID: 35081569 DOI: 10.1097/sla.0000000000005391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This systematic review and meta-analysis aims to review the contemporary literature comparing CABG and PCI in diabetic patients providing an up-to-date perspective on the differences between the interventions. BACKGROUND Diabetes is common and diabetic patients are at a 2-to-4-fold increased risk of developing coronary artery disease. Approximately 75% of diabetic patients die of cardiovascular disease. Previous literature has identified CABG as superior to PCI for revascularization in diabetic patients with complex coronary artery diseas. METHODS PubMed and Medline were systematically searched for articles published from January 1, 2015 to April 15, 2021. This systematic review included all retrospective, prospective, and randomized trial studies comparing CABG and PCI in diabetic patients. 1552 abstracts were reviewed and 25 studies were included in this review. The data was analyzed using the RevMan 5.4 software. RESULTS Diabetic patients undergoing CABG experienced significantly reduced rates of 5-year mortality, major adverse cardiovascular and cerebrovascular events, myocardial infarction, and required repeat revascularization. Patients who underwent PCI experienced improved rates of stroke that trended toward significance. CONCLUSIONS Previous literature regarding coronary revascularization in diabetic patients has consistently demonstrated superior outcomes for patients undergoing CABG over PCI. The development of 1st and 2nd generation DES have narrowed the gap between CABG and PCI, but CABG continues to be superior. Continued investigation with large randomized trials and retrospective studies including long term follow-up comparing CABG and 2nd generation DES is necessary to confirm the optimal intervention for diabetic patients.
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Anand PA, Keshavamurthy S, Shelley EM, Saha S. Does Age Affect the Short- and Long-Term Outcomes of Coronary Bypass Grafting? Int J Angiol 2021; 30:202-211. [PMID: 34776820 PMCID: PMC8580610 DOI: 10.1055/s-0041-1735221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The etiology of coronary artery disease (CAD) is multifactorial, stemming from both modifiable and nonmodifiable risk factors such as age. Several studies have reported the effects of age on various outcomes of coronary artery bypass grafting (CABG). This article reviews age-related outcomes of CABG and offers direction for further studies in the field to create comprehensive, evidence-based guidelines for the treatment of CAD. Ninety-two primary sources were analyzed for relevance to the subject matter, of which 17 were selected for further analysis: 14 retrospective cohort studies, 2 randomized clinical trials, and 1 meta-analysis. Our review revealed four broad age ranges into which patients can be grouped: those with CAD (1) below the age of 40 years, (2) between the ages of 40 and 60 years, (3) between the ages of 60 and 80 years, and (4) at or above 80 years. Patients below the age of 40 years fare best overall with total arterial revascularization (TAR). Patients between the ages of 40 and 60 years also fare well with the use of multiarterial grafts (MAGs) whereas either MAGs or single-arterial grafts may be of significant benefit to patients at or above the age of 60 years, with younger and diabetic patients benefitting the most. Arterial grafting is superior to vein grafting until the age of 80 years, at which point there is promising evidence supporting the continued use of the saphenous vein as the favored graft substrate. Age is a factor affecting the outcomes of CABG but should not serve as a barrier to offering patients CABG at any age from either a cost or a health perspective. Operative intervention starts to show significant mortality consequences at the age of 80 years, but the increased risk is countered by maintenance or improvement to patients' quality of life.
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Affiliation(s)
- Pavan Ashwini Anand
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Suresh Keshavamurthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Ellis M. Shelley
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Sibu Saha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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Gupta PK, Balachander J. Predictor of in-stent restenosis in patients with drug-eluting stent (PRIDE)- a retrospective cohort study. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2021; 33:184-194. [PMID: 33622608 DOI: 10.1016/j.arteri.2020.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND It is a fact that coronary artery disease (CAD) is more prevalent in India as compared to western countries. The major risk factors associated with the early CAD are a high prevalence of diabetes mellitus, atherogenic lipid profile, smoking habits, sedentary lifestyle, low socioeconomic condition and high prevalence of obesity. Is this true for restenosis after drug-eluting stent (DES) implantation and factors associated with it? The main objective of the study was to determine the rate of in-stent restenosis (ISR) in patients with DES and risk factors associated with it from our region. METHODS It was a single-center, retrospective cohort study in which 550 patients who underwent DES implantation were included. Patient's demographic data, coronary angiography findings, procedural characteristics and development of ISR were noted. RESULTS Out of 550 patients, 31 developed ISR with a rate of restenosis of 5.63% and target lesion revascularization (TLR) of 5.63%. On multiple Cox-regression analysis, only diabetes mellitus (DM) (p=0.008, adjusted hazard ratio (HR): 2.757, 95% confidence interval (CI): 1.296-5.863), deployment of stent in the left anterior descending (LAD) artery (p=0.031, adjusted HR: 3.342, 95% CI: 1.115-10.017) and periprocedural complication during percutaneous coronary intervention (p=0.040, adjusted HR: 2.824, 95% CI: 1.049-7.603) were found to be significantly associated with increased risk of ISR. Kaplan-Meier survival analysis of event-free survival for restenosis showed patients with DM had significantly lower event-free survival compared to patients without DM (p=0.005 by log-rank test). CONCLUSIONS In our study, the rate of restenosis after DES implantation was 5.63%. The presence of DM, the stent in the LAD territory and the periprocedural complication is strongly associated with the development of ISR.
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Affiliation(s)
- Praveen K Gupta
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India.
| | - Jayaram Balachander
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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