Remote Surgical Discussion of Multivessel Coronary Artery Disease Patients without Surgery on Site-Retrospective Insights

OBJECTIVE

The heart team approach is highly advocated for in treatment decision making in patients with multivessel disease (MVD). Nevertheless, many centers lack on-site cardiac surgical services (CSS)/formal heart team. Our local alternative is of remote surgical consultation without a structured image sharing platform. In our understanding, the incidence of anatomical complete revascularization (ACR) under this daily practice, and its clinical impact, has not been discussed before.

METHODS

We analyzed 477 consecutive patients who were surgically revascularized between January 2009 and March 2018 for MVD, after remote surgical consultation. Unstable, late arrival, and ST elevation patients were excluded (n = 163). ACR was considered grafting all anatomic lesions > 50%. Syntax score (SS) calculation and ACR categorization were determined by an independent interventionalist using diagnostic angiograms and available operative reports (n = 267). Patients' outcomes were assessed in relation to multiple clinical variables including troponin result and the revascularization status.

RESULTS

Three hundred and fourteen patients were included. Mean age was 64 years, and mean SS-II was 27.3 ± 11. At the 4-year follow-up, the observed mortality (11.8% and 12.9%, with troponin-positive and -negative groups, respectively), myocardial infarction (11.8%), and repeat revascularization (9.8%) were higher than those predicted using a nomogram depicting the predicted 4-year mortality as a function of the SYNTAX II Score (5.3%, 8.8%, and 3.5%, respectively, p = 0.02). ACR was reported in 33% of 267 available patients' reports. After multivariate adjustment ACR was the only variable associated with a significant increase in 4-year mortality (12.3% vs. 6.7%, p < 0.05).

CONCLUSIONS

Partial revascularization in the absence of on-site CSS and a structured heart team platform is a frequent occurrence. Not surprisingly, this occurrence was associated with a higher risk for mid-term mortality. An upfront, structured, virtual, heart team interface is mandatory to particularly prioritize the completeness of revascularization when considering the optimal revascularization mode.

Impact of repeat revascularization within 5 years on 10-year mortality after percutaneous or surgical revascularization

BACKGROUND

The SYNTAX trial demonstrated negative impact of repeat revascularization (RR) on 5-year outcomes following PCI/CABG in patients with three-vessel(3VD) and/or left main coronary artery disease(LMCAD). We aimed to investigate the impact of RR within 5 years, on 10-year mortality in patients with 3VD and/or LMCAD after PCI/CABG.

METHODS

The SYNTAXES study evaluated the vital status out to 10 years of patients with 3VD and/or LMCAD. Patients were stratified by RR within 5 years and randomized treatment. The association between RR within 5 years and 10-year mortality was assessed.

RESULTS

A total of 330 out of 1800 patients (18.3%) underwent RR within 5 years. RR occurred more frequently after initial PCI than after initial CABG (25.9% vs. 13.7%, p < 0.001). Overall, 10-year mortality was comparable between patients undergoing RR and those not (28.2% vs. 26.1%, adjusted HR: 1.17, 95%CI 0.93-1.48, p = 0.187). In the PCI arm, RR was associated with a trend toward higher 10-year mortality (adjusted HR: 1.29, 95%CI 0.97-1.72, p = 0.075), while in the CABG arm, the trend was opposite (adjusted HR: 0.74, 95%CI 0.46-1.20, p = 0.219). Among patients requiring RR, those who underwent PCI as initial revascularization had a higher risk of 10-year mortality compared to initial CABG (33.5% vs. 17.6%, adjusted HR: 2.09, 95%CI 1.21-3.61, p = 0.008).

CONCLUSION

In the SYNTAXES study, RR within 5 years had no impact on 10-year all-cause death in the population overall. Among patients requiring any repeat procedures, 10-year mortality was higher after initial treatment with PCI than after CABG. These exploratory findings should be investigated with larger populations in future studies.

TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov ; SYNTAXES Unique identifier: NCT03417050. URL: https://www.

CLINICALTRIALS

gov ; SYNTAX Unique identifier: NCT00114972.

The Role of Polymorphism in the Endothelial Homeostasis and Vitamin D Metabolism Genes in the Severity of Coronary Artery Disease

Coronary artery disease (CAD) remains one of the leading causes of cardiovascular morbidity and mortality worldwide. The maintenance of endothelial homeostasis and vitamin D metabolism play an important role in CAD pathogenesis. This study aimed to determine the association of endothelial homeostasis and vitamin D metabolism gene polymorphism with CAD severity. A total of 224 low-risk patients (SYNTAX score ≤ 31) and 36 high-risk patients (SYNTAX score > 31) were recruited for this study. The serum level of E-, L- and P-selectins; endothelin; eNOS; 25OH; and 1.25-dihydroxy vitamin D was measured using an enzyme-linked immunosorbent assay (ELISA). Polymorphic variants in SELE, SELP, SELPLG, END1, NOS3, VDR and GC were analyzed using a polymerase chain reaction (PCR). We found no differences in the serum levels of the studied markers between high- and low-risk patients. Three polymorphic variants associated with CAD severity were discovered: END1 rs3087459, END1 rs5370 and GC rs2298849 in the log-additive model. Moreover, we discovered a significantly decreased serum level of 1.25-dihydroxy vitamin D in high-risk CAD patients with the A/A-A/G genotypes of the rs2228570 polymorphism of the VDR gene, the A/A genotype of the rs7041 polymorphism of the GC gene and the A/A genotype of the rs2298849 polymorphism of the GC gene.

Impact of residual angina on long-term clinical outcomes after percutaneous coronary intervention or coronary artery bypass graft for complex coronary artery disease

AIMS

The aim of this study was to investigate the impact on 10-year survival of patient-reported anginal status at 1 year following percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in patients with left main coronary artery disease (LMCAD) and/or three-vessel CAD (3VD).

METHODS AND RESULTS

In this post hoc analysis of the randomized SYNTAX Extended Survival study, patients were classified as having residual angina (RA) if their self-reported Seattle Angina Questionnaire angina frequency (SAQ-AF) scale was ≤90 at the 1-year follow-up post-revascularization with PCI or CABG. The primary endpoint of all-cause death at 10 years was compared between the RA and no-RA groups. A sensitivity analysis was performed using a 6-month SAQ-AF.At 1 year, 373 (26.1%) out of 1428 patients reported RA. Whilst RA at 1 year was an independent correlate of repeat revascularization at 5 years [18.3 vs. 11.5%; adjusted hazard ratio (HR): 1.54; 95% confidence interval (CI): 1.10-2.15], it was not associated with all-cause death at 10 years (22.1 vs. 21.6%; adjusted HR: 1.11; 95% CI: 0.83-1.47). These results were consistent when stratified by the modality of revascularization (PCI or CABG) or by anginal frequency. The sensitivity analysis replicating the analyses based on 6-month angina status resulted in similar findings.

CONCLUSION

Among patients with LMCAD and/or 3VD, patient-reported RA at 1 year post-revascularization was independently associated with repeat revascularization at 5 years; however, it did not significantly increase 10-year mortality, irrespective of the primary modality of revascularization or severity of RA.

10 Years of SYNTAX: Closing an Era of Clinical Research After Identifying New Outcome Determinants

The SYNTAX trial randomized patients equally eligible for coronary artery bypass grafting or percutaneous coronary intervention using the Heart Team approach. The SYNTAXES study achieved a follow-up rate of 93.8% and reported the 10-year vital status. Factors associated with increased mortality at 10 years were pharmacologically treated diabetes mellitus, increased waist circumference, reduced left ventricular function, prior cerebrovascular and peripheral vascular disease, western Europe and North American descent, current smoking, chronic obstructive pulmonary disease, elevated C-reactive protein, anemia, and an increase in HbA1c. Procedural factors associated with higher 10 years mortality include periprocedural myocardial infarction, extensive stenting, small stents, ≥1 heavily calcified lesion, ≥1 bifurcation lesion, residual SYNTAX score >8, and staged percutaneous coronary intervention. Optimal medical therapy at 5 years, use of statins, on-pump coronary artery bypass grafting, multiple arterial grafts, and higher physical component score and mental component score were associated with lower mortality at 10 years. Numerous scores and prediction models were developed to help individualize risk assessment. Machine learning has emerged as a novel approach for developing risk models.

Can machine learning unravel unsuspected, clinically important factors predictive of long-term mortality in complex coronary artery disease? A call for 'big data'

Aims

Risk stratification and individual risk prediction play a key role in making treatment decisions in patients with complex coronary artery disease (CAD). The aim of this study was to assess whether machine learning (ML) algorithms can improve discriminative ability and identify unsuspected, but potentially important, factors in the prediction of long-term mortality following percutaneous coronary intervention or coronary artery bypass grafting in patients with complex CAD.

Methods and results

To predict long-term mortality, the ML algorisms were applied to the SYNTAXES database with 75 pre-procedural variables including demographic and clinical factors, blood sampling, imaging, and patient-reported outcomes. The discriminative ability and feature importance of the ML model was assessed in the derivation cohort of the SYNTAXES trial using a 10-fold cross-validation approach. The ML model showed an acceptable discrimination (area under the curve = 0.76) in cross-validation. C-reactive protein, patient-reported pre-procedural mental status, gamma-glutamyl transferase, and HbA1c were identified as important variables predicting 10-year mortality.

Conclusion

The ML algorithms disclosed unsuspected, but potentially important prognostic factors of very long-term mortality among patients with CAD. A 'mega-analysis' based on large randomized or non-randomized data, the so-called 'big data', may be warranted to confirm these findings.

Clinical Trial Registration

SYNTAXES ClinicalTrials.gov reference: NCT03417050, SYNTAX ClinicalTrials.gov reference: NCT00114972.

Cardiovascular Risk Factors, Angiographical Features and Short-Term Prognosis of Acute Coronary Syndrome in People Living with Human Immunodeficiency Virus: Results of a Retrospective Observational Multicentric Romanian Study

People living with human immunodeficiency virus have increased cardiovascular risk due to a higher prevalence of traditional and particular risk factors such as chronic inflammation, immune dysregulation, endothelial dysfunction, coagulation abnormalities and antiretroviral therapy. In developed countries, coronary artery disease has become the most frequent cardiovascular disease and an important cause of mortality in these patients. The symptomatology of an acute coronary syndrome can be atypical, and the prevalence of each type of acute coronary syndrome is reported differently. Regarding coronary artery disease severity in people living with HIV, the literature data indicates that the presence of single-vessel disease is akin to that of HIV-negative patients, and their short-term prognosis is unclear. This study aims to assess the clinical characteristics, biological parameters, angiographical features and short-term prognosis of acute coronary syndrome in a cohort of Romanian people living with human immunodeficiency virus.

Comparison of SYNTAX score strata effects of percutaneous and surgical revascularization trials: A meta-analysis

OBJECTIVES

The evidence supporting the use of the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) score for risk stratification is controversial. We performed a systematic review and meta-analysis of all the randomized controlled trials comparing percutaneous coronary intervention versus coronary artery bypass grafting that reported their outcomes stratified by SYNTAX score, focusing on between-strata comparisons.

METHODS

A systematic review of MEDLINE, EMBASE, Cochrane Library databases was performed. Incidence rate ratios were pooled with a random effect model. Between-group statistical heterogeneity according to accepted SYNTAX score tertiles was computed in the main analysis. Ratios of incidence rate ratios were computed to appraise between-strata effect, as sensitivity analysis. Primary and secondary outcomes were major adverse cardiac and cerebrovascular events and all-cause mortality, respectively. Separate sub-analyses were performed for left main and multivessel disease.

RESULTS

From 425 citations, 6 trials were eventually included (8269 patients [4134 percutaneous coronary interventions, 4135 coronary artery bypass graftings]; mean follow-up: 6.2 years [range: 3.8-10]). Overall, percutaneous coronary intervention was associated with a significant increase in major adverse cardiac and cerebrovascular events (incidence rate ratio, 1.39, 95% confidence interval, 1.27-1.51) and nonsignificant increase in all-cause mortality (incidence rate ratio, 1.17, 95% confidence interval, 0.98-1.40). There was no significant statistical heterogeneity of treatment effect by SYNTAX score for major adverse cardiac and cerebrovascular events or mortality (P = .40 and P = .34, respectively). Results were consistent also for patients with left main and multivessel disease (major adverse cardiac and cerebrovascular events: P = .85 in left main, P = .78 in multivessel disease 0.78; mortality: P = .12 in left main; P = .34 in multivessel disease). Results of analysis based on ratios of incidence rate ratios were consistent with the main analysis.

CONCLUSIONS

No significant association was found between SYNTAX score and the comparative effectiveness of percutaneous coronary intervention and coronary artery bypass grafting. These findings have implications for clinical practice, future guidelines, and the design of percutaneous coronary intervention versus coronary artery bypass grafting trials.

The BEST trial is here - but is anyone listening?

The long-term outcome of the Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease trial has recently been published. This appraisal provides a critical evaluation of the main findings of the study.

Quantitative Prediction of SYNTAX Score for Cardiovascular Artery Disease Patients via the Inverse Problem Algorithm Technique as Artificial Intelligence Assessment in Diagnostics

The quantitative prediction of the SYNTAX score for cardiovascular artery disease patients using the inverse problem algorithm (IPA) technique in artificial intelligence was explored in this study. A 29-term semi-empirical formula was defined according to seven risk factors: (1) age, (2) mean arterial pressure, (3) body surface area, (4) pre-prandial blood glucose, (5) low-density-lipoprotein cholesterol, (6) Troponin I, and (7) C-reactive protein. Then, the formula was computed via the STATISTICA 7.0 program to obtain a compromised solution for a 405-patient dataset with a specific loss function [actual-predicted]² as low as 3.177, whereas 0.0 implies a 100% match between the prediction and observation via "the lower, the better" principle. The IPA technique first created a data matrix [405 × 29] from the included patients' data and then attempted to derive a compromised solution of the column matrix of 29-term coefficients [29 × 1]. The correlation coefficient, r², of the regression line for the actual versus predicted SYNTAX score was 0.8958, showing a high coincidence among the dataset. The follow-up verification based on another 105 patients' data from the same group also had a high correlation coefficient of r² = 0.8304. Nevertheless, the verified group's low derived average AT (agreement) (AT_avg = 0.308 ± 0.193) also revealed a slight deviation between the theoretical prediction from the STATISTICA 7.0 program and the grades assigned by clinical cardiologists or interventionists. The predicted SYNTAX scores were compared with earlier reported findings based on a single-factor statistical analysis or scanned images obtained by sonography or cardiac catheterization. Cardiologists can obtain the SYNTAX score from the semi-empirical formula for an instant referral before performing a cardiac examination.

Predicted and Observed Mortality at 10 Years in Patients With Bifurcation Lesions in the SYNTAX Trial

BACKGROUND

Percutaneous coronary intervention (PCI) of bifurcation lesions is associated with higher rates of adverse events, and currently it is unclear whether PCI or coronary artery bypass grafting (CABG) is the safer treatment for these patients at very long-term follow-up.

OBJECTIVES

The aim of this study was to investigate the impact of bifurcation lesions on individual predicted and observed all-cause 10-year mortality in the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial.

METHODS

In the SYNTAXES (SYNTAX Extended Survival) study, 10-year observed and individual predicted mortality derived from the SYNTAX score 2020 (SS-2020) was compared between patients with ≥1 bifurcation (n = 1,300) and those with no bifurcations (n = 487).

RESULTS

Among patients treated with PCI, patients with >1 bifurcation lesion compared with those without bifurcation lesions had a significantly higher risk for all-cause death (19.8% vs 30.1%; HR: 1.55; 95% CI: 1.12-2.14; P = 0.007), whereas following CABG, mortality was similar in patients with and those without bifurcation lesions (23.3% vs 23.0%; HR: 0.81; 95% CI: 0.59-1.12; P = 0.207; P_interaction = 0.006). In PCI patients, a 2-stent vs a 1-stent technique was associated with higher mortality (33.3% vs 25.9%; HR: 1.51; 95% CI: 1.06-2.14; P = 0.021). According to the SS-2020, among those with ≥1 bifurcation, there was equipoise for all-cause mortality between PCI and CABG in 2 quartiles of the population, whereas CABG was superior to PCI in the 2 remaining quartiles.

CONCLUSIONS

Bifurcation lesions require special attention from the heart team, considering the higher 10-year all-cause mortality associated with PCI. Careful evaluation of bifurcation lesion complexity and calculation of individualized 10-year prognosis using the SS-2020 may therefore be helpful in decision making. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; Taxus Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).

10-Year All-Cause Mortality Following Percutaneous or Surgical Revascularization in Patients With Heavy Calcification

OBJECTIVES

The aim of this study was to assess 10-year all-cause mortality in patients with heavily calcified lesions (HCLs) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

BACKGROUND

Limited data are available on very long term outcomes in patients with HCLs according to the mode of revascularization.

METHODS

This substudy of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study assessed 10-year all-cause mortality according to the presence of HCLs within lesions with >50% diameter stenosis and identified during the calculation of the anatomical SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score among 1,800 patients with the 3-vessel disease and/or left main disease randomized to PCI or CABG in the SYNTAX trial. Patients with HCLs were further stratified according to disease type (3-vessel disease or left main disease) and assigned treatment (PCI or CABG).

RESULTS

The 532 patients with ≥1 HCL had a higher crude mortality rate at 10 years than those without (36.4% vs 22.3%; HR: 1.79; 95% CI: 1.49-2.16; P < 0.001). After adjustment, an HCL remained an independent predictor of 10-year mortality (HR: 1.36; 95% CI: 1.09-1.69; P = 0.006). There was a significant interaction in mortality between treatment effect (PCI and CABG) and the presence or absence of HCLs (P_interaction = 0.005). In patients without HCLs, mortality was significantly higher after PCI than after CABG (26.0% vs 18.8%; HR: 1.44; 95% CI: 0.97-1.41; P = 0.003), whereas in those with HCLs, there was no significant difference (34.0% vs 39.0%; HR: 0.85; 95% CI: 0.64-1.13; P = 0.264).

CONCLUSIONS

At 10 years, the presence of an HCL was an independent predictor of mortality, with a similar prognosis following PCI or CABG. Whether HCLs require special consideration when deciding the mode of revascularization beyond their current contribution to the anatomical SYNTAX score deserves further evaluation. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).

Serum Gamma Glutamyltransferase (GGT) in coronary artery disease: Exploring the Asian Indian Connection

BACKGROUND

There is a need to identify novel markers for CAD, independent of traditional CV risk factors. One of these is gamma-glutamyl transferase (GGT), a marker of increased oxidative stress. Given the high prevalence of CAD in Asian Indians, the link of GGT and CAD in them needs to be studied.

AIM

To assess GGT in patients with angiographically documented CAD.

METHODS AND RESULTS

Two hundred patients aged 58.1 ± 9.95 years, 73% males, hypertension 56%, diabetes 40% were included. Mean GGT was 63.6 ± 44.33 (10-269 U/L). The levels of GGT progressively increased in those with single/double or triple-vessel CAD (36.5, 61.5, and 87 U/L, respectively, P &lt; 0.001). Using objective criteria of CAD burden (SYNTAX and Gensini scores), we reaffirmed these findings. GGT in patients with SYNTAX tertiles 0-22, 23-32, and ≥ 33 was 33, 62, and 97 U/L, respectively and in Gensini tertiles 0-17.65, 17.66-56.65, ≥56.66 was 32, 52, and 88 U/L, respectively, all P &lt; 0.001. SYNTAX score ≥ 23 was present in only 23% patients in GGT tertile 1 (&lt;41 U/L), whereas60% and 94% in GGT tertiles 2 and 3 had SYNTAX ≥ 23. Significant positive correlation was seen between GGT and SYNTAX (r = 0.634) and Gensini score (r = 0.772).

CONCLUSIONS

In this study, GGT had an independent correlation with angiographic severity of CAD and SYNTAX and Gensini scores. Although the existing evidence seems biologically plausible, more studies are needed to explore the potential role of this inexpensive marker for predicting disease burden in patients with CAD.

Comparison of multiple risk scores in assessing medium-to long-term clinical outcomes in unstable angina / non-ST-elevation myocardial infarction patients undergoing multi vessel percutaneous coronary intervention: An observational, registry-based study in India

Objective

Post-revascularization mortality in multivessel coronary artery disease (MVCAD) has been explored via several risk scores. Here, we assessed and compared various risk scores in predicting medium to long-term clinical outcomes in unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) patients with MVCAD undergoing percutaneous coronary intervention (PCI).

Methods

We analyzed a cohort of a tertiary care center registry enrolling patients in South India, Kerala, with MVCAD (N = 200) who had undergone PCI between 2010 and 2018. The outcomes evaluated were all-cause mortality and major adverse cardiac events (MACE). The risk scores assessed included SYNTAX score (SS), residual SYNTAX score (rSS), SYNTAX revascularization index (SRI), age, creatinine, and ejection fraction (ACEF) score, clinical SYNTAX score (cSS), and SYNTAX score II (SSII).

Results

Of the analyzed risk scores, SSII had the best predictive capability with the area under the curve (AUC) of 0.79 in c-statistics, followed by ACEF score and cSS with AUCs of 0.74 and 0.65, respectively for all-cause mortality (p < 0.01). Kaplan–Meier survival curves and multivariate analysis by Cox regression showed SSII with cut-offs of >35.15 and > 29.55 to be the only score associated with higher mortality and MACE, respectively.

Conclusions

In UA/NSTEMI patients with relatively less complex MVCAD treated by PCI, the SSII, ACEF and cSS risk scores could predict the outcomes better. The SSII showed the best predictive performance for all-cause mortality and MACE. Scores based on baseline and residual atherosclerotic burden (SS, rSS, and SRI) performed poorly in predicting the mortality and MACE.

Long-term survival after coronary bypass surgery with multiple versus single arterial grafts

OBJECTIVES

This study sought to evaluate the long-term differences in survival between multiple arterial grafts (MAG) and single arterial grafts (SAG) in patients who underwent coronary artery bypass grafting (CABG) in the SYNTAX study.

METHODS

The present analysis included the randomized and registry-treated CABG patients (n = 1509) from the SYNTAX Extended Survival study (SYNTAXES). Patients with only venous (n = 42) or synthetic grafts (n = 1) were excluded. The primary end point was all-cause death at the longest follow-up. Multivariable Cox regression was used to adjust for differences in baseline characteristics. Sensitivity analysis using propensity matching with inverse probability for treatment weights was performed.

RESULTS

Of the 1466 included patients, 465 (31.7%) received MAG and 1001 (68.3%) SAG. Patients receiving MAG were younger and at lower risk. At the longest follow-up of 12.6 years, all-cause death occurred in 23.6% of MAG and 40.0% of SAG patients [adjusted hazard ratio (HR) 0.74, 95% confidence interval (CI) (0.55-0.98); P = 0.038], which was confirmed by sensitivity analysis. MAG in patients with the three-vessel disease was associated with significant lower unadjusted and adjusted all-cause death at 12.6 years [adjusted HR 0.65, 95% CI (0.44-0.97); P = 0.033]. In contrast, no significance was observed after risk adjustment in patients with the left main disease, with and without diabetes, or among SYNTAX score tertiles.

CONCLUSIONS

In the present post hoc analysis of all-comers patients from the SYNTAX trial, MAG resulted in markedly lower all-cause death at 12.6-year follow-up compared to a SAG strategy. Hence, this striking long-term survival benefit of MAG over SAG encourages more extensive use of multiple arterial grafting in selected patients with reasonable life expectancy.

TRIAL REGISTRATION

SYNTAXES ClinicalTrials.gov reference: NCT03417050; SYNTAX ClinicalTrials.gov reference: NCT00114972.

Ten-year all-cause death after percutaneous or surgical revascularization in diabetic patients with complex coronary artery disease

Aims

The aim of this article was to compare rates of all-cause death at 10 years following coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in patients with or without diabetes.

Methods and results

The SYNTAXES study evaluated up to 10-year survival of 1800 patients with three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD) randomized to receive either PCI or CABG in the SYNTAX trial. Ten-year all-cause death according to diabetic status and revascularization strategy was examined. In diabetics (n = 452), the risk of mortality was numerically higher with PCI compared with CABG at 5 years [19.6% vs. 13.3%, hazard ratio (HR): 1.53, 95% confidence interval (CI): 0.96, 2.43, P = 0.075], with the opposite seen between 5 and 10 years (PCI vs. CABG: 20.8% vs. 24.4%, HR: 0.82, 95% CI: 0.52, 1.27, P = 0.366). Irrespective of diabetic status, there was no significant difference in all-cause death at 10 years between patients receiving PCI or CABG, the absolute treatment difference was 1.9% in diabetics (PCI vs. CABG: 36.4% vs. 34.5%, difference: 1.9%, 95% CI: −7.6%, 11.1%, P = 0.551). Among insulin-treated patients (n = 182), all-cause death at 10 years was numerically higher with PCI (47.9% vs. 39.6%, difference: 8.2%, 95% CI: −6.5%, 22.5%, P = 0.227).

Conclusions

The treatment effects of PCI vs. CABG on all-cause death at 10 years in patients with 3VD and/or LMCAD were similar irrespective of the presence of diabetes. There may, however, be a survival benefit with CABG in patients with insulin-treated diabetes. The association between revascularization strategy and very long-term ischaemic and safety outcomes for patients with diabetes needs further investigation in dedicated trials.

Trial registration

SYNTAX: ClinicalTrials.gov reference: NCT00114972 and SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050.

Impact of Optimal Medical Therapy on 10-Year Mortality After Coronary Revascularization

BACKGROUND

The benefit of optimal medical therapy (OMT) on 5-year outcomes in patients with 3-vessel disease and/or left main disease after percutaneous coronary intervention or coronary artery bypass grafting (CABG) was demonstrated in the randomized SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial.

OBJECTIVES

The objective of this analysis is to assess the impact of the status of OMT at 5 years on 10-year mortality after percutaneous coronary intervention or CABG.

METHODS

This is a subanalysis of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study, which evaluated for up to 10 years the vital status of patients who were originally enrolled in the SYNTAX trial. OMT was defined as the combination of 4 types of medications: at least 1 antiplatelet drug, statin, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and beta-blocker. After stratifying participants by the number of individual OMT agents at 5 years and randomized treatment, a landmark analysis was conducted to assess the association between treatment response and 10-year mortality.

RESULTS

In 1,472 patients, patients on OMT at 5 years had a significantly lower mortality at 10 years compared with those on ≤2 types of medications (13.1% vs 19.9%; adjusted HR: 0.470; 95% CI: 0.292-0.757; P = 0.002) but had a mortality similar to those on 3 types of medications. Furthermore, patients undergoing CABG with the individual OMT agents, antiplatelet drug and statin, at 5 years had lower 10-year mortality than those without.

CONCLUSIONS

In patients with 3-vessel and/or left main disease undergoing percutaneous coronary intervention or CABG, medication status at 5 years had a significant impact on 10-year mortality. Patients on OMT with guideline-recommended pharmacologic therapy at 5 years had a survival benefit. (Synergy Between PCI With Taxus and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; Taxus Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).

6-year results of BiOSS stents in coronary bifurcation treatment

BACKGROUND

The wide variation in bifurcation anatomy has generated an ongoing search for stents explicitly designed for coronary bifurcations, and to date, results have been underachieved.

METHODS

The POLBOS I and POLBOS II were international, multicentre, randomized, open-label, controlled trials. Patients were randomly assigned to BiOSS Expert (in POLBOS I, biodegradable polymer eluting paclitaxel)/BiOSS LIM (in POLBOS II, biodegradable polymer eluting sirolimus) stent implantation or regular drug-eluting stent (rDES) deployment. A provisional T-stenting strategy was the default treatment option. The primary endpoint of this pooled data study was the cumulative rate of major adverse cardiovascular events (MACE) consisting of cardiac death, myocardial infarction (MI) and target lesion revascularization (TLR). Telephone follow-up was performed annually up to 72 months. (ClinicalTrials.gov Identifier: POLBOS I-NCT02192840, POLBOS II-NCT02198300).

RESULTS

The total study population consisted of 445 patients, 222 patients in the BiOSS group and 223 patients in the rDES group. The follow-up rate was 93.7% in the BiOSS group and 91.9% in the rDES group. At 72 months, there was no significant difference between BiOSS and rDES groups regarding MACE (25.7% vs 25.1%, HR 1.06, 95% CI 0.73-1.52), cardiac death (3.1% vs 4.0%, HR 0.94, 95% CI 0.43-2.34), MI (3.6% vs 4.9%, HR 0.76, 95% CI 0.32-2.89), TLR (18.9% vs 16.1%, HR 1.17, 95% CI 0.75-1.83) and stent thrombosis rates (0.9% vs 0.5%, HR 1.21, 95CI 0.75-2.09).

CONCLUSIONS

At the 6-year follow-up, clinically significant clinical events did not differ between BiOSS stents and rDES.

10-Year Follow-Up After Revascularization in Elderly Patients With Complex Coronary Artery Disease

BACKGROUND

The optimal revascularization strategy for the elderly with complex coronary artery disease remains unclear.

OBJECTIVES

The goal of this study was to investigate 10-year all-cause mortality, life expectancy, 5-year major adverse cardiac or cerebrovascular events (MACCE), and 5-year quality of life (QOL) after percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in elderly individuals (>70 years old) with 3-vessel disease (3VD) and/or left main disease (LMD).

METHODS

In the present pre-specified analysis on age of the SYNTAX Extended Survival study, 10-year all-cause death and 5-year MACCE were compared with Kaplan-Meier estimates and Cox proportional hazards models among elderly or nonelderly patients. Life expectancy was estimated by restricted mean survival time within 10 years, and QOL status according to the Seattle Angina Questionnaire up to 5 years was assessed by linear mixed-effects models.

RESULTS

Among 1,800 randomized patients, 575 patients (31.9%) were elderly. Ten-year mortality did not differ significantly between PCI and CABG in elderly (44.1% vs. 41.1%; hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 0.84 to 1.40) and nonelderly patients (21.1% vs. 16.6%; HR: 1.30; 95% CI: 1.00 to 1.69; p_interaction = 0.332). Among elderly patients, 5-year MACCE was comparable between PCI and CABG (39.4% vs. 35.1%; HR: 1.18; 95% CI: 0.90 to 1.56), whereas it was significantly higher in PCI over CABG among nonelderly patients (36.3% vs. 23.0%; HR: 1.69; 95% CI: 1.36 to 2.10; p_interaction = 0.043). There were no significant difference in life expectancy (mean difference: 0.2 years in favor of CABG; 95% CI: -0.4 to 0.7) and 5-year QOL status between PCI and CABG among elderly patients.

CONCLUSIONS

Elderly patients with 3VD and/or LMD had comparable 10-year all-cause death, life expectancy, 5-year MACCE, and 5-year QOL status irrespective of revascularization mode. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050) (SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).

The Impact of War-Related Stress on Coronary Artery Disease Severity in War Survivors: A SYNTAX Study

Background: Due to the strong relationship between stress and heart disease, particularly acute myocardial infarction (MI), this study investigated the complexity of coronary artery disease (CAD) among Syrian refugee patients referred to Jordan University Hospital and its relation to war-related stressors. Methods: This is a retrospective study that utilized the SYNTAX I score in order to evaluate all Syrian refugees that underwent coronary artery catheterization at Jordan University Hospital during the period between May of 2014 and December of 2017. Results: There was a significant association between war-related stressors and high SYNTAX score (SX score), thus indicating a higher complexity of CAD in Syrian war survivors with higher stress scores. The strongest war-related correlation was observed with crossing green-lines, in which Syrian refugee patients who had crossed such lines had significantly higher SYNTAX scores. Regression analysis demonstrated that war stressors were positive predictors of increased SYNTAX scores even when adjusted for conventional CAD risk factors. Surprisingly, none of the CAD risk factors were significantly associated with SYNTAX score. Conclusion: Our findings suggest that exposure to multiple war-related stressors may increase the complexity and severity of CAD in Syrian war survivors. Thus, special attention, efforts, and resources should be allocated to screen for such vulnerable patients in order to provide them with the appropriate healthcare.

Impact of chronic obstructive pulmonary disease on 10-year mortality after percutaneous coronary intervention and bypass surgery for complex coronary artery disease: insights from the SYNTAX Extended Survival study

Aims

To evaluate the impact of chronic obstructive pulmonary disease (COPD) on 10-year all-cause death and the treatment effect of CABG versus PCI on 10-year all-cause death in patients with three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD) and COPD.

Methods

Patients were stratified according to COPD status and compared with regard to clinical outcomes. Ten-year all-cause death was examined according to the presence of COPD and the revascularization strategy.

Results

COPD status was available for all randomized 1800 patients, of whom, 154 had COPD (8.6%) at the time of randomization. Regardless of the revascularization strategy, patients with COPD had a higher risk of 10-year all-cause death, compared with those without COPD (43.1% vs. 24.9%; hazard ratio [HR]: 2.03; 95% confidence interval [CI]: 1.56–2.64; p < 0.001). Among patients with COPD, CABG appeared to have a slightly lower risk of 10-year all-cause death compared with PCI (42.3% vs. 43.9%; HR: 0.96; 95% CI: 0.59–1.56, p = 0.858), whereas among those without COPD, CABG had a significantly lower risk of 10-year all-cause death (22.7% vs. 27.1%; HR: 0.81; 95% CI: 0.67–0.99, p = 0.041). There was no significant differential treatment effect of CABG versus PCI on 10-year all-cause death between patients with and without COPD (p_interaction = 0.544).

Conclusions

COPD was associated with a higher risk of 10-year all-cause death after revascularization for complex coronary artery disease. The presence of COPD did not significantly modify the beneficial effect of CABG versus PCI on 10-year all-cause death.

Trial registration: SYNTAX: ClinicalTrials.gov reference: NCT00114972. SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050

Graphic abstract

Sex Differences in All-Cause Mortality in the Decade Following Complex Coronary Revascularization

BACKGROUND

The poorer prognosis of coronary artery disease in females compared with males is related mainly to differences in baseline characteristics. In the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial, the effect of treatment with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting surgery (CABG) on mortality at 5 years differed significantly between females and males; however, the optimal revascularization beyond 5 years according to sex has not been evaluated.

OBJECTIVES

The aim of this study was to investigate the impact of sex on mortality and sex-treatment interaction at 10 years.

METHODS

The SYNTAXES (SYNTAX Extended Survival) study evaluated vital status up to 10 years in 1,800 patients with de novo 3-vessel and/or left main coronary artery disease randomized to treatment with PCI or CABG in the SYNTAX trial. All-cause death at 10 years was separately evaluated in female and male patients with complex coronary artery disease.

RESULTS

Of 1,800 patients, 402 (22.3%) were female and 1,398 (77.7%) were males. Females had a higher 10-year mortality rate compared with males (32.8% vs. 24.7%; log-rank p = 0.002), but female sex was not an independent predictor of mortality (adjusted hazard ratio: 1.02; 95% confidence interval: 0.76 to 1.36). Mortality at 10 years tended to be lower after CABG than after PCI, with a similar treatment effect for female and male patients (adjusted hazard ratio for females: 0.90 [95% confidence interval: 0.54 to 1.51]; adjusted hazard ratio for males: 0.76 [95% confidence interval: 0.56 to 1.02]; p for interaction = 0.952).

CONCLUSIONS

Female sex was not an independent predictor of mortality at 10 years in patients with complex coronary artery disease. The interaction between sex and treatment with PCI or CABG that was observed at 5 years was no longer present at 10 years. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).

Mortality 10 Years After Percutaneous or Surgical Revascularization in Patients With Total Coronary Artery Occlusions

BACKGROUND

The long-term clinical benefit after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with total occlusions (TOs) and complex coronary artery disease has not yet been clarified.

OBJECTIVES

The objective of this analysis was to assess 10-year all-cause mortality in patients with TOs undergoing PCI or CABG.

METHODS

This is a subanalysis of patients with at least 1 TO in the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study, which investigated 10-year all-cause mortality in the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial, beyond its original 5-year follow-up. Patients with TOs were further stratified according to the status of TO recanalization or revascularization.

RESULTS

Of 1,800 randomized patients to the PCI or CABG arm, 460 patients had at least 1 lesion of TO. In patients with TOs, the status of TO recanalization or revascularization was not associated with 10-year all-cause mortality, irrespective of the assigned treatment (PCI arm: 29.9% vs. 29.4%; adjusted hazard ratio [HR]: 0.992; 95% confidence interval [CI]: 0.474 to 2.075; p = 0.982; and CABG arm: 28.0% vs. 21.4%; adjusted HR: 0.656; 95% CI: 0.281 to 1.533; p = 0.330). When TOs existed in left main and/or left anterior descending artery, the status of TO recanalization or revascularization did not have an impact on the mortality (34.5% vs. 26.9%; adjusted HR: 0.896; 95% CI: 0.314 to 2.555; p = 0.837).

CONCLUSIONS

At 10-year follow-up, the status of TO recanalization or revascularization did not affect mortality, irrespective of the assigned treatment and location of TOs. The present study might support contemporary practice among high-volume chronic TO-PCI centers where recanalization is primarily offered to patients for the management of angina refractory to medical therapy when myocardial viability is confirmed. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).

The relationship of body composition indices with the significance, extension and severity of coronary artery disease

BACKGROUND AND AIMS

It is still unclear which anthropometric parameter is most associated with significant coronary artery disease (CAD). We examined the relationship of the prevalence and severity of coronary artery disease with body composition indices.

METHODS AND RESULTS

Patients aged 18-80 years who were admitted to the cardiology outpatient clinic with any complaints, and were indicated for coronary angiography as a result of the examinations, were included in this study and divided into two groups. Group 1 had significant stenosis (161 patients, 104 males, mean age: 64.1 ± 10.5 years), while Group 2 had non-significant stenosis (75 patients, 48 males, mean age: 58.9 ± 11.8 years). Significant stenosis was defined as narrowing of 50% or more of the arterial lumens in any vessel or its lateral branch. Height, weight, waist and hip circumferences and body composition indices of all patients were measured. The SYNTAX and Gensini scores were calculated for all patients undergoing angiography. Group 1 had significantly higher waist circumferences (WC), body roundness indices (BRI), body fat percentages, and waist/height ratios than Group 2. In the correlation analysis, WC, BRI, waist/hip ratio and waist/height ratio were significantly correlated with the Gensini score. WC, hip circumference, BRI, body fat percentage and waist/height ratio were significantly correlated with the SYNTAX score. In the multivariate regression analysis, BRI was the parameter best related to significant CAD.

CONCLUSION

BRI, body fat percentage, waist circumference and waist/height ratio were higher in patients with significant stenosis. BRI was the parameter most closely related to the Gensini and SYNTAX scores and to significant CAD.

Lipoprotein(a) levels are associated with coronary severity but not with outcomes in Chinese patients underwent percutaneous coronary intervention

BACKGROUND AND AIMS

The association between lipoprotein(a) [Lp(a)] levels and the risk of cardiovascular disease is of great interest but still controversial. This study sought to investigate the impact of Lp(a) on coronary severity and long-term outcomes of patients who undergo percutaneous coronary intervention (PCI).

METHODS AND RESULTS

A total of 6714 consecutive patients who received PCI were enrolled to analyze the association between Lp(a) and coronary severity and major adverse cardiovascular and cerebrovascular events (MACCE). Patients were divided into tertiles according to Lp(a) levels on admission. Coronary severity was evaluated by SYNTAX scoring system. The MACCE included recurrent myocardial infarction, unplanned target vessel revascularization, stent thrombosis, ischemic stroke and all-cause mortality. Significantly, Lp(a) levels were positively associated with coronary severity (p < 0.001). Multivariate logistic regression analyses showed Lp(a) was an independent predictor of intermediate to high SYNTAX score. During an average of 874 days follow-up, 755 patients presented with MACCE (11.25%) were reported. The incidence rates of MACCE, all-cause mortality, cardiac death, target vessel revascularization, recurrent myocardial infarction, stent thrombosis, stroke and bleeding were not statistically different among the Lp(a) tertile groups. Furthermore, both Kaplan-Meier and Cox regression analyses found no relationship between Lp(a) and cardiovascular outcomes (p > 0.05).

CONCLUSION

Lp(a) is an independent predictor of the prevalence of more complex coronary artery lesions (SYNTAX score ≥ 23) in patients with PCI. In addition, our study has shown that Lp(a) has no relationship with long-term cardiovascular outcomes in Chinese patients with PCI.

Outcomes of Bilateral Internal Thoracic Arteries in Minimally Invasive Coronary Artery Bypass Grafting With Analogy to the SYNTAX Trial

OBJECTIVES

Minimally invasive CABG is making positive strides in the evolution of coronary artery bypass surgery. We carried out a retrospective study of the efficacy and outcomes of the usage of bilateral internal thoracic arteries in MICS CABG patients over a 6 year period using primary (MACCE) and secondary outcome measures and also carried out a subgroup analysis of patients with diabetes and methodology of revascularization, and with analogy to the SYNTAX trial of the relative risk.

METHODS

Nine hundred and forty patients underwent multivessel MICS CABG via a left mini-thoracotomy from August 2011 to September 2017 and complete revascularization was done using the left internal thoracic artery-right internal thoracic artery Y (LITA-RITA Y) composite conduit. Efficacy and outcomes were evaluated by primary (MACCE) and secondary outcome measures including total length of stay, return to full physical activity, and quality of life. Propensity score matched analyses were carried out in diabetics, in the methodology of revascularization (MICS OPCABG vs. MICS ONCABG), and by comparison to the SYNTAX trial for relative risk. Mean follow-up was 2.9 years (maximum was 5.6 years).

RESULTS

Out of the 940 patients, 843 (89.6%) were diabetic and 97 (10.4%) were nondiabetic. Average grafts were 3.2. There were 9 mortalities (0.9%). The average ICU and hospital stay was 40 ± 12 hours and 3.1 days. Ten patients (1.06%) required reintervention by angioplasty. A total of 99.3% patients were free from major adverse cardiac and cerebrovascular events (MACCE) at follow-up. Mean follow-up was 33 months and 846 (90%) of the patients were followed up. Based on propensity score-matched groups, patients who had their surgery done by MICS ONCABG (beating heart technique) had greater mean number of grafts and hospital length of stay and had significantly longer ICU stay, extubation in OR and blood loss in comparison to patients who had their CABG done by the MICS OPCABG technique. The new technique has shown favorable risk reduction in comparison to both the arms of the SYNTAX trial.

CONCLUSIONS

The safety, efficacy and outcomes of minimally invasive CABG evaluated by primary (MACCE) and secondary outcomes and quality-of-life measures have been good in this study, especially in diabetics, and have shown results better than conventional CABG. The learning curve can be safely negotiated by using peripheral cardiopulmonary bypass assistance and comparison with the SYNTAX trial has shown a relative reduction in all-cause risk.

Percutaneous or surgical revascularization for left main stem disease: NOBLE ideas, but do they EXCEL?

Introduction: Although coronary artery bypass grafting (CABG) has traditionally been the standard treatment for significant left main stem (LMS) disease, percutaneous coronary intervention (PCI) using drug-eluting stents (DES) is now considered an acceptable alternative. Areas covered: This article aims to summarise the key findings of the landmark clinical trials on LMS revascularization and the recently published ESC/EACTS guidelines on myocardial revascularization related to LMS disease. Expert opinion: It is unlikely that there will be a further large randomized trial aimed at addressing the issue of the optimum method of revascularization for LMS disease. Both PCI and CABG are reasonable revascularization options for appropriately selected patients with LMS disease. 'Heart Team' approach is vital to guide the management of patients with LMS disease, when there is obvious clinical equipoise and a mandate for complete revascularization. With an aging and increasing co-morbid patient population, clinical equipoise may not always be obvious, making extrapolation of clinical trial results to the 'real world' difficult.

Elevated lipoprotein(a) and low-density lipoprotein cholesterol as predictors of the severity and complexity of angiographic lesions in patients with premature coronary artery disease

BACKGROUND

Elevated lipoprotein(a) (Lp[a]) and low-density lipoprotein (LDL) cholesterol are important inheritable risk factors for premature coronary artery disease (CAD). Lp(a) mediates cardiovascular risk through prothrombotic, proinflammatory, and proatherogenic properties. The association of Lp(a) and LDL cholesterol with angiographic disease severity and complexity in patients with premature CAD has yet to be established.

OBJECTIVE

To investigate the relationship of Lp(a) and LDL cholesterol with the severity and complexity of coronary artery lesions using the SYNergy between percutaneous coronary intervention with TAXUS and Cardiac Surgery (SYNTAX) and Gensini scores, in patients with premature CAD.

METHODS

Plasma Lp(a) levels were consecutively measured by an automated latex-enhanced immunoassay in 147 patients with premature coronary events (aged <60 years). Elevated Lp(a) was defined as >0.5 g/L, and elevated LDL cholesterol as an untreated LDL cholesterol of >5.0 mmol/L (>193 mg/dL). Demographical, biochemical, and clinical data were retrospectively collected from medical records. SYNTAX and Gensini scores were independently assessed by 2 investigators.

RESULTS

Patients were subdivided into tertiles using SYNTAX scores. The proportion of patients with elevated Lp(a) and elevated LDL cholesterol were significantly higher in patients with higher SYNTAX and Gensini scores (P < .05). In multivariate analysis (adjusting for age, diabetes, hypertension, and previous coronary event), elevated Lp(a) and elevated LDL cholesterol remained significant, independent predictors of higher SYNTAX and Gensini scores (P < .05). Patients with both elevated Lp(a) and elevated LDL cholesterol constituted most of the patients in the highest SYNTAX tertile, while patients with nonelevated Lp(a) and nonelevated LDL cholesterol were predominantly in the lowest SYNTAX tertile (P < .05).

CONCLUSION

In patients with premature CAD, elevated Lp(a) and LDL cholesterol (in a range consistent with familial hypercholesterolemia) were significant, independent predictors of the severity of CAD. Both lipid disorders should be routinely screened for in younger patients presenting to the coronary care unit.

Residual SYNTAX score following coronary artery bypass grafting

Objectives

To quantify residual coronary artery disease measured using the SYNTAX score (SS) and its relation to outcomes after coronary artery bypass grafting (CABG).

Methods

We conducted a retrospective analysis on a consecutive series of 1608 patients [mean age 68 years, standard deviation (SD): 7, F:M, 242:1366] undergoing first-time isolated CABG from 2004 to 2015. The baseline SS was retrospectively determined from preoperative angiograms, and the residual SS (rSS) was measured during assessment of the actual operative report for each patient after CABG. Patients were then stratified according to tercile cut points of low (rSS low 0-11, N  = 537), intermediate (rSS mid  >11-18.5, N  = 539) and high residual SS (rSS high  >18.5, N  = 532). The Cox regression model was used to investigate the impact of rSS on major adverse cardiac and cerebrovascular events (MACCE) at 1 year.

Results

The mean preoperative SS was 26.6 (SD: 9.4) (range 10.1-53), and the residual SS after CABG was 15.3 (SD: 8.4) (range 0-34) ( P  <   0.001 versus preoperative). At 1 year, cumulative incidence of MACCE in the low rSS was 1.5% ( N  = 8/537), 4.5% ( N  = 24/539) in the intermediate and 8.8% ( N  = 47/532) in the high rSS group. Kaplan-Meier analysis showed a statistically significant difference of MACCE-free survival between the three groups (log-rank test, P  <   0.001). The estimated MACCE-free survival rate at 1 year was 98.1% [standard error (SE): 1.6] for the rSS low , 95.5% (SE: 1.9) for the rSS mid , and 90.5% (SE: 1.3) for the rSS high group, respectively. After multivariable adjustment, the rSS high group was independently associated with a higher incidence of MACCE at 1 year (hazard ratio 1.92, 95% confidence interval 1.21-3.23) compared to the rSS low group.

Conclusions

These unanticipated findings suggest that a residual SS may be a useful tool for risk stratification of patients undergoing isolated first-time CABG. Our study may set the stage for further investigations addressing this important clinical question.

Circulating PCSK9 levels in acute coronary syndrome: Results from the PC-SCA-9 prospective study

BACKGROUND

Serum proprotein convertase subtilisin/kexin type 9 (PCSK9) concentrations have been shown to be positively associated with LDL cholesterol (LDL-C), but the relationship between PCSK9 and coronary atherosclerosis lesions remains unclear.

OBJECTIVE

This study aims to investigate the correlation between serum PCSK9 levels and coronary damage severity in patients hospitalized for acute coronary syndrome (ACS).

METHODS

In this prospective proof-of-concept study, coronary lesions were assessed using SYNTAX scores. Serum PCSK9 concentrations were measured on admission (Day 0) for ACS by Elisa, and on every day of hospitalization. Spearman's correlations were used to determine the association between PCSK9 levels, SYNTAX score and metabolic parameters.

RESULTS

A total of 174 patients (mean age: 59±14 years, 79% male) with ACS (on Day 0, 119 patients were not taking statins, but 55 were) were included. After initiation of high-intensity statin therapy, serum PCSK9 concentrations increased significantly, reaching maximum levels on Day 2 (+31% vs. Day 0), and remained stable up to Day 4 (P<0.001, by mixed model). Serum PCSK9 on Day 0 was associated with LDL-C (rho=0.226, P=0.017) and apolipoprotein B (rho=0.282, P=0.005) in the statin-naïve group only, and with triglycerides and non-HDL-C in all groups. More important, PCSK9 levels on Day 0 were positively associated with SYNTAX scores in the statin-naïve group (rho=0.239, P=0.009), but not in the statin-treated group (P=NS). This association was maintained after adjusting for LDL-C (P=0.014) and major CV risk factors (P=0.008).

CONCLUSION

Serum PCSK9 levels are positively associated with severity of coronary artery lesions independently of LDL-C concentrations in patients hospitalized for ACS. This reinforces the potential importance of PCSK9 inhibition in the management of ACS.

The impact of diabetes on the association between epicardial fat thickness and extent and complexity of coronary artery disease in patients with non-ST elevation myocardial infarction

BACKGROUND

Epicardial fat thickness (EFT) is associated with increased cardio metabolic risk. Recent studies have suggested that there is a strong relationship between diabetes and EFT. Although the relationship between EFT and coronary artery disease (CAD) is well known, the possible impact of diabetes on the relationship between EFT and extent and complexity of CAD was not fully investigated.

AIM

We aimed to investigate the relationship between EFT and extent and complexity of CAD in patients with non-ST elevation myocardial infarction (NSTEMI) with and without diabetes.

METHODS

We prospectively included 454 patients with NSTEMI (mean age: 61.8 ± 10.4 years) in the present study. Patients were classified into two groups according to their diabetes status (diabetic group and non-diabetic group). EFT was measured by transthoracic echocardiography on the right ventricle in individuals having the left lateral decubitus position. SYNTAX score was used to define the extent and complexity of CAD. High-sensitivity C-reactive protein (hs-CRP) and other biochemical markers were measured in all participants.

RESULTS

Diabetic patients had higher EFT values compared with non-diabetics (p < 0.05). EFT is independently associated with diabetes, SYNTAX score, and hs-CRP in all patients (p < 0.05, for all). When patients were divided into two groups, as diabetic and non-diabetic, the association between EFT and SYNTAX score was stronger in diabetic patients compared with non-diabetics (r = 0.635; p < 0.001 vs. r = 0.179; p = 0.003).

CONCLUSIONS

Epicardial fat thickness is associated with SYNTAX score in both diabetic and non-diabetic patients. Furthermore, there is a stricter relationship between EFT and SYNTAX score in diabetic patients.

Causes of Death Following PCI Versus CABG in Complex CAD: 5-Year Follow-Up of SYNTAX

BACKGROUND

There are no data available on specific causes of death from randomized trials that have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI).

OBJECTIVES

The purpose of this study was to investigate specific causes of death, and its predictors, after revascularization for complex coronary disease in patients.

METHODS

An independent Clinical Events Committee consisting of expert physicians who were blinded to the study treatment subclassified causes of death as cardiovascular (cardiac and vascular), noncardiovascular, or undetermined according to the trial protocol. Cardiac deaths were classified as sudden cardiac, related to myocardial infarction (MI), and other cardiac deaths.

RESULTS

In the randomized cohort, there were 97 deaths after CABG and 123 deaths after PCI during a 5-year follow-up. After CABG, 49.4% of deaths were cardiovascular, with the greatest cause being heart failure, arrhythmia, or other causes (24.6%), whereas after PCI, the majority of deaths were cardiovascular (67.5%) and as a result of MI (29.3%). The cumulative incidence rates of all-cause death were not significantly different between CABG and PCI (11.4% vs. 13.9%, respectively; p = 0.10), whereas there were significant differences in terms of cardiovascular (5.8% vs. 9.6%, respectively; p = 0.008) and cardiac death (5.3% vs. 9.0%, respectively; p = 0.003), which were caused primarily by a reduction in MI-related death with CABG compared with PCI (0.4% vs. 4.1%, respectively; p <0.0001). Treatment with PCI versus CABG was an independent predictor of cardiac death (hazard ratio: 1.55; 95% confidence interval: 1.09 to 2.33; p = 0.045). The difference in MI-related death was seen largely in patients with diabetes, 3-vessel disease, or high SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries) trial scores.

CONCLUSIONS

During a 5-year follow-up, CABG in comparison with PCI was associated with a significantly reduced rate of MI-related death, which was the leading cause of death after PCI. Treatments following PCI should target reducing post-revascularization spontaneous MI. Furthermore, secondary preventive medication remains essential in reducing events post-revascularization. (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).

Predictors of Peak Troponin Level in Acute Coronary Syndromes: Prior Aspirin Use and SYNTAX Score

The peak troponin level has been associated with cardiovascular (CV) mortality and adverse CV events. The association of peak troponin with CV risk factors and severity and complexity of coronary artery disease remains unknown. We assessed the predictors of peak troponin in patients with acute coronary syndrome (ACS). This study aims to determine the predictors of peak troponin in ACS. Cardiac catheterization (CC) reports and electronic medical records from 2010 to 2013 were retrospectively reviewed. A total of 219 patients were eligible for the study. All major CV risk factors, comorbidities, laboratory data, CC indications, and coronary lesion characteristics were included. Univariate and multivariate regression analyses were done. On multivariate linear regression analysis, ST-elevation myocardial infarction (p = 0.001, β = 65.16) and increasing synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) score (p = 0.002, β = 1.15) were associated with higher peak troponin. The Pearson correlation between SYNTAX score and peak troponin was r = 0.257, p = 0.001. History of daily aspirin use was associated with lower peak troponin (p = 0.002, β = -24.32). Prior statin use (p = 0.321, β = -8.98) and the presence of CV risk factors were not associated with peak troponin. Coronary artery disease severity and complexity, urgency of CC, and prior aspirin use are associated with peak troponin levels in ACS. Our findings may help predict patient population with ACS who would be at a greater risk for short- and long-term CV morbidity and mortality due to elevated peak troponin.

Comparison of coronary risk scoring systems to predict the severity of coronary artery disease using the SYNTAX score

BACKGROUND

Reliable risk scoring systems that can predict the severity of coronary artery disease (CAD) are necessary to implement effective management strategies in high-risk patients. Atherosclerotic vascular disease and with cardiovascular morbidity and mortality risk are patients who would benefit most from a change in patients at high risk factors. Framingham Risk Score, the Prospective Cardiovascular Münster (PROCAM) score and Systematic Coronary Risk Evaluation (SCORE) risk scores are used for this purpose. The severity of the CAD as detected by coronary angiography can be estimated using the SYNTAX score. In this study, it is aimed to assess the relation between SYNTAX score and the Framingham, PROCAM and SCORE scores in the context of their utility for the determination of the severity of the CAD.

METHODS

A total of 205 patients with documented CAD who underwent coronary angiography due to a diagnosis of stable angina pectoris were included in this study. Coronary risk scores were determined for each patient. The relation between the SYNTAX score and the results of coronary risk scoring systems were analyzed.

RESULTS

A positive relationship between the SYNTAX score, which reflects the severity of the CAD and coronary risk scores was found. However, Framingham and SCORE were superior, i.e., had more predictive value, regarding their ability to predict the SYNTAX score (p = 0.029, 0.033 and 0.002, respectively).

CONCLUSIONS

Examination of the distribution of SYNTAX score across low, intermediate and high-risk groups showed a significantly higher predictive value of SCORE for high-risk patients (p = 0.005).

The impact of a second arterial graft on 5-year outcomes after coronary artery bypass grafting in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery Trial and Registry

OBJECTIVE

Despite various evidence supporting the advantages of multiple arterial grafting, inconsistencies in use of the procedure have resulted in high variability in the acceptance and practice of arterial grafting. The purpose of this study was to assess the effects of an arterial versus venous second grafts on outcomes at 5-year follow-up in the coronary artery bypass grafting population from the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial.

METHODS

Patients (n = 1419) with an arterial graft to the left anterior descending artery and ≥1 other graft were included and divided according to the second graft's type: 2nd-graft-arterial group (n = 456) and 2nd-graft-venous group (n = 963). Five-year outcomes were compared between subgroups. Event rates were estimated with Kaplan-Meier analyses. Propensity-score matching was used, to control for selection bias due to nonrandom group assignment in a 1:1 manner, resulting in 432 pairs with balanced baseline characteristics.

RESULTS

In unmatched groups, the 2nd-graft-arterial group had significantly lower rates of death (8.9% vs 13.1%; P = .02), and composite safety endpoint of death/stroke/myocardial infarction (13.3% vs 18.7%; P = .02), compared with the 2nd-graft-venous group. The rate of major adverse cardiac or cerebrovascular events was similar between groups (22.9% vs 25.5%; P = .30), because it includes the rate of repeat revascularization (12.6% in the 2nd-graft-arterial group vs 9.6% in the 2nd-graft-venous group; P = .10). After propensity-score matching, no statistically significant differences were found between groups.

CONCLUSIONS

This study reveals comparable 5-year outcomes with arterial and venous conduits as second grafts after an arterial graft anastomosed to the left anterior descending artery. This study demonstrates the multi-institutional variation in patient selection and operator technique with regard to arterial revascularization, although extended follow-up beyond 5 years is required to estimate its impact on long-term outcomes.

CLINICAL TRIAL NUMBER

NCT00114972.

Coronary collateral circulation in patients with chronic coronary total occlusion; its relationship with cardiac risk markers and SYNTAX score

BACKGROUND

Compared to patients without a collateral supply, long-term cardiac mortality is reduced in patients with well-developed coronary collateral circulation (CCC). Cardiovascular risk markers, such as N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitive C-reactive protein (hs-CRP) and high-sensitive cardiac troponin T (hs-cTnT) are independent predictors for cardiovascular mortality.

OBJECTIVES

The main goal of this study was to examine the relationship between CCC and cardiovascular risk markers.

METHODS

We prospectively enrolled 427 stable coronary artery disease patients with chronic total occlusion (mean age: 57.5±11.1 years). The patients were divided into two groups, according to their Rentrop scores: (a) poorly developed CCC group (Rentrop 0 and 1) and (b) well-developed CCC group (Rentrop 2 and 3). NT-proBNP, hs-CRP, hs-cTnT, uric acid and other biochemical markers were also measured. The SYNTAX score was calculated for all patients.

RESULTS

The patients in the poorly developed CCC group had higher frequencies of diabetes and hypertension (p<0.05 for both). Compared to the well-developed CCC group, the SYNTAX score, Hs-cTnT, hs-CRP, NT-proBNP, uric acid, neutrophil count and mean platelet volume (MPV) values were higher in patients with poorly developed CCC (p<0.05 for all). On multivariate logistic regression analysis, hs-cTnT (β=0.658, 95% CI=0.589-0.735, p<0.001) and NT-proBNP (β=0.991, 95% CI=0.987-0.995, p<0.001) as well as hs-CRP and diabetes were independent predictors of CCC.

CONCLUSION

Cardiac risk markers, such as NT-proBNP, hs-cTnT and hs-CRP are independently associated with CCC in stable coronary artery disease with chronic total occlusion.

Relationship between SYNTAX score and Trans-Atlantic Inter-Society Consensus II classification in patients undergoing diagnostic angiography

Introduction

Peripheral artery disease (PAD) is a marker of systemic atherosclerosis and most patients with PAD also have concomitant coronary artery disease (CAD).

Aim

There are no published data investigating the relationship between PAD and CAD complexity assessed by a well-accepted classification system such as the SYNTAX score (SS) or Trans-Atlantic Inter-Society Consensus II (TASC II).

Material and methods

The study population consisted of 72 patients who underwent coronary angiography for the assessment of CAD. At the same session, peripheral angiography was performed in cases of suspected PAD. A coronary lesion was defined as significant if it caused a 50% reduction of the luminal diameter by visual estimation in vessels ≥ 1.5 mm. The SYNTAX score was computed by dedicated software.

Results

Patients with peripheral artery disease were divided into four groups according to the Trans-Atlantic Inter-Society Consensus II classification. Numbers of patients with peripheral artery disease classified as A, B, C, and D by the Trans-Atlantic Inter-Society Consensus II classification were 27, 16, 18 and 11, respectively. SYNTAX scores for each group from A to D were 10 ±9, 11 ±10, 24 ±13 and 27 ±12, respectively; p for trend < 0.001.

Conclusions

Higher Trans-Atlantic Inter-Society Consensus II classification is associated with higher SYNTAX score in patients who underwent coronary and peripheral diagnostic angiography. It may suggest that arterial atherosclerotic disease complexity is a systemic panvascular phenomenon.

Serum 25-hydroxyvitamin D level and extent and complexity of coronary artery disease

BACKGROUND

There are limited number of studies about relationship between serum vitamin D level and presence and severity of coronary artery disease (CAD). We assessed the relationship between the extent and complexity of CAD assessed by SYNTAX score and 25-hydroxyvitamin D level in patients with stable CAD.

METHODS

In the study, 209 consecutive patients with stable CAD (age: 63.1 ± 10.0 years) and 102 healthy control subjects (age 61.3 ± 13.7 years) were included. Serum 25-hydroxyvitamin D was measured using a direct competitive chemiluminescent immunoassay and other biochemical markers were measured in all subjects. All subjects underwent coronary angiography and SS was calculated.

RESULTS

The mean serum 25-hydroxyvitamin D level of CAD group was lower than the control group (P < 0,001). Multivariate regression analysis showed that serum 25-hydroxyvitamin D level was independently associated with SYNTAX score (β = -0.396, P < 0.001), hypertension (β = -0.183, P = 0.003), high sensitive C-reactive protein (β = -0.141, P = 0.014), and body mass index (β = -0.135, P = 0.023) in patient group.

CONCLUSION

25-Hydroxyvitamin D level was associated with extent and complexity of CAD. 25-Hydroxyvitamin D may play a role in pathogenesis and severity of coronary atherosclerosis.

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.

Incidence, correlates, and significance of abnormal cardiac enzyme rises in patients treated with surgical or percutaneous based revascularisation: a substudy from the Synergy between Percutaneous Coronary Interventions with Taxus and Cardiac Surgery (SYNTAX) Trial

AIMS

The aim of the present investigation was to determine the long-term prognostic association of post-procedural cardiac enzyme elevation within the randomised Synergy between Percutaneous Coronary Intervention (PCI) with TAXUS and Cardiac Surgery (SYNTAX) Trial.

METHODS

1800 patients with unprotected left main or de novo three-vessel coronary artery disease were randomised to undergo coronary artery bypass graft (CABG) surgery or PCI. Per protocol patients underwent post-procedural blood sampling with creatine kinase (CK), and the cardiac specific MB iso-enzyme (CK-MB) only if the preceding CK ratio was ≥ 2 × the upper limit of normal (ULN). An independent chemistry laboratory evaluated all collected blood samples.

RESULTS

Post-procedural CK sampling was available in 1629 of 1800 patients (90.5%). As per protocol, CK-MB analyses were undertaken in 474 of 491 patients (96.5%) in the CABG arm, and 53 of 61 patients (86.9%) in the PCI arm. Within the CABG arm, despite the limitations of incomplete data, a post-procedural CK-MB ratio <3/≥3 ULN separated 4-year mortality into low- and high-risk groups (2.3% vs. 9.5%, p=0.03). Additionally, in the CABG arm, a post-procedural CK-MB ratio ≥3 ULN was associated with an increased frequency of a high SYNTAX Score (≥33) tertile (high [≥33] SYNTAX Score: 39.5%, intermediate [23-32] SYNTAX Score 31.0%, low [≤22] SYNTAX Score 29.5%, p=0.02). Within the PCI arm, a post-procedural CK ratio of <2 or ≥2 ULN separated 4-year mortality into low- and high-risk groups (10.8% vs. 23.3%, p=0.001). Notably, there was an early (within 6 months) and late (after 2 years) peak in mortality in patients with a post-PCI CK ratio of ≥2 ULN. Lack of pre-procedural thienopyridine, carotid artery disease, type 1 diabetes, and presence of coronary bifurcations were independent correlates of a CK ratio ≥2 ULN post-PCI.

CONCLUSION

Cardiac enzyme elevations post-CABG or post-PCI are associated with an adverse long-term mortality; the causes of which are multifactorial.

Fractional flow reserve-guided coronary artery bypass grafting: can intraoperative physiologic imaging guide decision making? J Thorac Cardiovasc Surg. 2013;146:824-835.e1. [PMID: 23915918 DOI: 10.1016/j.jtcvs.2013.06.026]

OBJECTIVES

Fractional flow reserve-guided coronary artery bypass grafting is emerging in cardiac surgery, in which the nature (anatomic and functional characteristics) of the target vessel epicardial coronary artery stenosis is important in graft site selection. The nature of the stenosis might determine a different physiologic response to bypass grafting. We report our recent experience using near infrared fluorescence complex angiography and perfusion analysis to identify the nature of stenoses in the target vessel by imaging the physiologic response to grafting.

METHODS

In 167 patients who underwent consecutive multivessel coronary artery bypass grafting cases (63% off-pump coronary artery bypass grafting) with traditional anatomy-based revascularization, we imaged and analyzed 359 grafts (53% arterial). This platform provides angiographic data of both the target vessel epicardial coronary artery and graft simultaneously (to assess the imaged competitive flow); and because a change in fluorescence intensity is proportional to the change in blood flow and perfusion, the quantified change (if any) in regional myocardial perfusion surrounding the grafted target vessel epicardial coronary artery.

RESULTS

The patient outcomes in our series were excellent. All 359 grafts were widely patent by angiography, and 24% of the arterial and 22% of the saphenous vein grafts showed no regional myocardial perfusion change in response to bypass grafting. In 165 in situ internal mammary artery grafts to the left anterior descending artery (>70% stenosis), 40 had no change in regional myocardial perfusion, and 32 of the 40 had competitive flow imaged.

CONCLUSIONS

An important number of angiographically patent bypass grafts demonstrated no change in regional myocardial perfusion, suggesting anatomic, but nonfunctional, stenoses in those target vessel epicardial coronary arteries. In in situ arterial grafts, imaged competitive flow is associated with nonfunctional stenoses in the target vessel epicardial coronary artery. Imaging these physiologic responses to target vessel revascularization might be useful in the emerging fractional flow reserve-guided era.