Prognosis of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafts for Ostial Right Coronary Lesions in Propensity‐Matched Individuals

Objective: Our aim was to evaluate the relative safety and efficacy of percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) versus coronary artery bypass grafts (CABG) for the treatment of ostial right coronary stenosis (ORCS) lesions. Methods: Three hundred fifty‐nine cases of ORCS lesion were treated via CABG (n = 232) or PCI (n = 127) procedures. Propensity scores for undergoing the CABG procedure were estimated and used to match 105 pairs of patients between the two groups. Kaplan–Meier major adverse cardiac and cerebrovascular events (MACCE)‐free curves were constructed to compare long‐term MACCE‐free survival between the two groups. Results: For the 105 propensity‐matched pairs, patients were more likely to undergo repeat revascularization with CABG in the PCI group than in the CABG group during the first 30 days (4 cases vs. 0 case, P= 0.043, χ²= 4.08) and the 1‐year follow‐up (5 cases vs. 0 case, P= 0.02, χ²= 5.17). With a mean follow‐up of 12.04 ± 6.47 months and a total of 210.67 patient–years, the freedom from MACCE in the CABG group was significantly higher than that in the PCI group (Log rank test, χ²= 4.48, P= 0.03). There were no significant differences in the rates of death, myocardial infarction, nonfatal stroke, death/myocardium infarction/stroke, or repeated PCI between the two groups during the first 30 days and during the 1‐year follow‐up period. Conclusion: For OCRS lesions, CABG provided greater protection than PCI procedure in terms of freedom from MACCE, mainly due to the reduced number of repeated revascularization procedures. CABG should be considered as first‐choice revascularization strategy for ORCS lesions.     

Validating the EXCEL hypothesis: A propensity score matched 3‐year comparison of percutaneous coronary intervention versus coronary artery bypass graft in left main patients with SYNTAX score ≤32

Objectives : The aim of this study is to verify the study hypothesis of the EXCEL trial by comparing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in an EXCEL‐like population of patients. Background : The upcoming EXCEL trial will test the hypothesis that left main patients with SYNTAX score ≤32 experience similar rates of 3‐year death, myocardial infarction (MI), or cerebrovascular accidents (CVA) following revascularization by PCI or CABG. Methods : We compared the 3‐year rates of death/MI/CVA and death/MI/CVA/target vessel revascularization (MACCE) in 556 patients with left main disease and SYNTAX score ≤32 undergoing PCI (n = 285) or CABG (n = 271). To account for confounders, outcome parameters underwent extensive statistical adjustment. Results : The unadjusted incidence of death/MI/CVA was similar between PCI and CABG (12.7% vs. 8.4%, P = 0.892), while MACCE were higher in the PCI group compared to the CABG group (27.0% vs. 11.8%, P < 0.001). After propensity score matching, PCI was not associated with a significant increase in the rate of death/MI/CVA (11.8% vs. 10.7%, P = 0.948), while MACCE were more frequently noted among patients treated with PCI (28.8% vs. 14.1%, P = 0.002). Adjustment by means of SYNTAX score and EUROSCORE, covariates with and without propensity score, and propensity score alone did not change significantly these findings. Conclusions : In an EXCEL‐like cohort of patients with left main disease, there seems to be a clinical equipoise between PCI and CABG in terms of death/MI/CVA. However, even in patients with SYNTAX score ≤32, CABG is superior to PCI when target vessel revascularization is included in the combined endpoint. © 2011 Wiley‐Liss, Inc.     

One‐Year Follow‐Up of Nonrandomized Comparison between Coronary Artery Bypass Grafting Surgery and Drug‐Eluting Stent for the Treatment of Unprotected Left Main Coronary Artery Disease in Elderly Patients (Aged ≥75 Years)

Purpose: The present observational study compares in‐hospital and 12‐month clinical outcomes in elderly patients with unprotected left main coronary artery disease treated either with coronary artery bypass grafting or drug‐eluting stent. Methods: From January 2004 to December 2007, 211 patients (pts) with unprotected left main coronary artery (ULMCA) stenosis, aged 75 or older, underwent coronary revascularization either with coronary artery bypass graft (CABG) (106 pts) or drug‐eluting stent (DES) (105 pts). The decision to treat with CABG or percutaneous coronary intervention (PCI) was dependent on the patient's and the physician's choice. The occurrence of major adverse cardiac or cerebrovascular events (MACCE: death, nonfatal myocardial infarction, or stroke) and revascularizations was recorded after 1 year of follow‐up. A multivariate logistic regression analysis was performed using a propensity score method to take potential baseline differences between groups into account. Results: In‐hospital MACCE rates were 5.7% and 3.8% in the CABG and PCI groups, respectively (P = 0.748). After 1 year of follow‐up, these rates were, respectively, 13.9% and 14.9% (P = 0.841), and rates for target vessel revascularization at 12 months were 1.0% and 13.9% (P < 0.001). The PCI group was significantly associated with older age, dyslipidemia, history of cancer, high Euroscore, elevated creatininemia, single‐vessel disease, fewer chronic occlusions of the left anterior descending artery, and more LMCA stenosis ≥70%. The multivariate logistic regression analysis was adjusted for age, diabetes, left ventricular ejection fraction, Euroscore, and plasma creatininemia and stratified on the score of propensity to be treated with PCI. In the subgroup below median propensity score, the adjusted odds ratio for 1‐year MACCE was OR = 0.91 (95% confidence interval: 0.14 to 5.98; P = 0.924) whereas OR was 0.16 (0.04–0.69; P = 0.013) in the subgroup above median propensity score. Conclusions: In patients with a high probability of being treated with PCI (older age, high Euroscore, high creatininemia, single‐vessel disease, …), the 1‐year risk of MACCE was significantly lower in PCI‐ than in CABG‐treated subjects. No significant difference was found in other cases.     

药物洗脱支架置入术与冠状动脉旁路移植术治疗冠心病多支病变的临床对比研究

目的:探讨药物洗脱支架(DES)治疗冠心病多支冠状动脉(冠脉)病变患者的临床疗效,并与冠脉旁路移植术进行比较.方法:入选2005-01-2008-01在我院行血管重建术的215例冠心病多支冠脉病变患者,其中114例行DES置入术(DES组),101例行冠脉旁路移植术 (CABG组).比较2组住院期和随访期不良心血管事件(死亡、非致死性心肌梗死、再次血管重建术和脑血管意外)的发生情况.结果:2组的临床和冠脉病变特征相似, 与DES组比较,CABG组左主干病变(29.2%∶5.0%,P<0.01)、LVEF<50%发生率(39.7%∶19.2%,P<0.01) 和完全血管重建率(81.2%∶58.8%, P<0.01)较高.住院期2组总体不良心血管事件发生率无明显差异,但CABG组住院期病死率有增高趋势(6.9%∶1.8%,P＞0.05).平均临床随访12～36(17±9)个月,2组总体不良心血管事件发生率仍无明显差异(9.6% ∶13.4%,P＞0.05) ,但DES组再次血管重建的发生率较CABG组有增高趋势(9.8%∶2.1%,P＞0.05).结论:DES置入术应用在冠心病多支冠脉病变患者中安全可行,总体不良心血管事件发生率与CABG无明显差异.     

Coronary artery bypass surgery versus percutaneous coronary intervention with drug-eluting stent implantation in patients with multivessel coronary disease

BACKGROUND: Drug-eluting stents (DES) constitute a major breakthrough in restenosis prevention after percutaneous coronary intervention (PCI). This study compared the clinical outcomes of PCI using DES versus coronary artery bypass graft (CABG) in patients with multivessel coronary artery disease (MVD) in real-world. METHODS: From January 2003 to December 2004, 466 consecutive patients with MVD underwent revascularization, 235 by PCI with DES and 231 by CABG. The study end-point was the incidence of major adverse cardiovascular events (MACEs) at the first 30 days after procedure and during follow-up. RESULTS: Most preoperative characteristics were similar in the two groups, but left main disease (24.7% vs 2.6%, P<0.001) and three-vessel disease (65% vs 54%, P = 0.02) were more prevalent in CABG group. The number of coronary lesions was also greater in CABG group (3.7 +/- 1.1 vs 3.3 +/- 1.1, P<0.001). Despite higher early morbidity (3.9% vs 0.8%, P = 0.03) associated with CABG, there were no significant differences in composite MACEs at the first 30 days between the two groups. During follow-up (mean 25+/-8 months), the incidence of death, myocardial infarction, or cerebrovascular event was similar in both groups (PCI 6.3% vs CABG 5.6%, P = 0.84). However, bypass surgery still afforded a lower need for repeat revascularization (2.8% vs 10.4%, p = 0.001). Consequently, overall MACE rate (14.5% vs 7.9%, P = 0.03) remained higher after PCI. CONCLUSION: PCI with DES is a safe and feasible alternative to CABG for selected patients with MVD. The reintervention gap was further narrowed in the era of DES. Aside from restenosis, progression of disease needs to receive substantial emphasis.     

无保护左主干病变冠状动脉搭桥术与雷帕霉素洗脱支架治疗的对比研究

目的:回顾性分析无保护左主干病变患者使用雷帕霉素洗脱支架(DES)的经皮冠状动脉介入治疗(PCI)与冠状动脉旁路移植手术(CABG)治疗的中、远期疗效,并探讨应用SYNTAX SCORE来评估病变风险与临床事件的相关性。方法:本研究回顾性收集了176例无保护左主干病变患者,其中CABG组80例,PCI-DES组96例。收集患者的基本情况、左主干病变特点及SYNTAX评分、CABG和PCI手术情况,随访患者术后3年的主要不良心脑血管事件(MACCE)的发生率。结果:术后3年随访,PCI-DES组与CABG组的MACCE发生率及无MACCE生存率比较差异无统计学意义,但PCI组靶血管再次血运重建率(TVR)明显高于CABG组(P<0.05)。用SYNTAX SCORE把PCI-DES和CABG两组患者分为高积分组(≥30.0)和低积分组(<30.0):高积分组,术后3年PCI-DES亚组MACCE事件发生率高于CABG亚组(23.53%∶18.05%,P<0.05),无MACCE事件生存率低于CABG亚组(51.47%∶70.83%,P<0.05)。低积分组,术后3年MACCE事件发生率CABG亚组高于PCI-DES亚组(12.50%∶7.14%,P>0.05),而无MACCE事件生存率低于PCI-DES亚组(75.00%∶82.14%,P<0.05)。结论:PCI-DES与CABG治疗无保护左主干病变患者总体疗效相似。用SYNTAX SCORE指导无保护左主干病变血管重建方式的选择有重要价值,但在不同的患者人群中,仍应结合临床特征和冠状动脉病变特点选择恰当的血运重建术。     

Percutaneous versus surgical revascularization for multivessel coronary artery disease: A single center 10 year follow‐up of SOS trial patients

Objectives: To compare 10 year outcomes including death, left ventricular ejection fraction (LVEF), major adverse cardiovascular and cerebrovascular events (MACCE), repeat revascularization (RR), and severity of angina (CCS) after randomization to stent supported percutaneous coronary intervention (PCI) or surgical revascularization (CABG) in a single center participating in the SOS trial. Background: Randomized studies show increased RR following PCI, but otherwise similar results to CABG in selected mutlivessel disease patients with up to 5 year follow up. There is no 10 year data available. Materials and methods: The analysis involved 100 patients randomized into the SOS study in Poland. Results: Patients were well matched for baseline demographic and angiographic characteristics. During 9.6 ± 0.85 year observation, there was no significant difference between groups for survival, CCS, and LVEF. Increased RR occurred following PCI; 21 (42%) vs. 9 (18%), P < 0.05. As a consequence, the MACCE was also significantly higher following PCI; 36 (72%) vs. 28 (56%), P < 0.05. Excess RR predominantly occurred in the first year and diminished over time with numerically less RR following PCI from year 5 to 10; 2 (4%) vs. 7 (14%), P = ns. Conclusions: These findings suggest that patients with multivessel coronary artery disease technically suitable for either stent supported PCI or CABG have very similar 10 year outcomes with respect to mortality, angina class, LVEF, and MACCE other than RR. Excess RR following PCI predominantly occurs in early years and is numerically lower following PCI in years 5–10. This underscores the need for longer‐term follow up from randomized trials. © 2009 Wiley‐Liss, Inc.     

Comparing mortality between coronary artery bypass grafting and percutaneous coronary intervention with drug-eluting stents in elderly with diabetes and multivessel coronary disease

Coronary artery disease is a critical issue that requires physicians to consider appropriate treatment strategies, especially for elderly people who tend to have several comorbidities, including diabetes mellitus (DM) and multivessel disease (MVD). Several studies have been conducted comparing clinical outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in patients with DM and MVD. However, elderly people were excluded in those clinical studies. Therefore, there are no comparisons of clinical outcomes between CABG and PCI in elderly patients with DM and MVD. We compared all-cause mortality between PCI with drug-eluting stents (DES) and CABG in elderly patients with DM and MVD. A total of 483 (PCI; n = 256, CABG; n = 227) patients were analyzed. The median follow-up period was 1356 days (interquartile range of 810–1884). The all-cause mortality rate was not significantly different between CABG and PCI with DES groups. The CABG group had more patients with complex coronary lesions such as three-vessel disease or a left main trunk lesion. Older age, hemodialysis, and reduced LVEF were associated with increased long-term all-cause mortality in a multivariable Cox regression analysis. The rate of all-cause mortality was not significantly different between the PCI and CABG groups in elderly patients with DM and MVD in a single-center study.     

Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.

OBJECTIVES: This study evaluated the clinical outcomes of consecutive, selected patients treated with coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main coronary artery (ULMCA) disease. BACKGROUND: Although recent data suggest that PCI with DES provides better clinical outcomes compared to bare-metal stenting for ULMCA disease, there is a paucity of data comparing PCI with DES to CABG. METHODS: Since April 2003, when DES first became available at our institution, 123 patients underwent CABG, and 50 patients underwent PCI with DES for ULMCA disease. RESULTS: High-risk patients (Parsonnet score >15) comprised 46% of the CABG group and 64% of the PCI group (p = 0.04). The 30-day major adverse cardiac and cerebrovascular event (MACCE) rate for CABG and PCI was 17% and 2% (p < 0.01), respectively. The mean follow-up was 6.7 +/- 6.2 months in the CABG group and 5.6 +/- 3.9 months in the PCI group (p = 0.26). The estimated MACCE-free survival at six months and one year was 83% and 75% in the CABG group versus 89% and 83% in the PCI group (p = 0.20). By multivariable Cox regression, Parsonnet score, diabetes, and CABG were independent predictors of MACCE. CONCLUSIONS: Despite a higher percentage of high-risk patients, PCI with DES for ULMCA disease was not associated with an increase in immediate or medium-term complications compared with CABG. Our data suggest that a randomized comparison between the two revascularization strategies for ULMCA may be warranted.     

Outcomes from patients with multi‐vessel disease following primary PCI

Background: CABG and PCI are effective means for revascularization of patients with multi‐vessel coronary artery disease, but previous studies have not focused on treatment of patients that first undergo primary PCI. Methods: Among patients enrolled in the global registry of acute coronary events (GRACE), clinical outcomes for patients presenting with STEMI treated with primary PCI were compared according to whether residual stenoses were treated medically, surgically, or with staged PCI. Clinical characteristics and data pertaining to major adverse cardiac events during hospitalization and 6 months after discharge were collected. Results: Of the 1,705 patients included, 1,345 (79%) patients were treated medically, 303 (18%) underwent staged PCI, and 57 (3.3%) underwent CABG following primary PCI. Hospital mortality was lowest among patients treated with staged PCI (Medical = 5.7%; PCI = 0.7%; CABG = 3.5%; P < 0.001 [PCI vs. Medical]), a finding that persisted after risk adjustment (Odds Ratio PCI vs. Medical = 0.16, [0.04–0.68]; P = 0.01). Six month postdischarge mortality likewise was lowest in the staged PCI group (Medical = 3.1%; PCI = 0.8%; CABG = 4.0%; P = 0.04 [PCI vs. Medical]). Patients revascularized surgically were rehospitalized less frequently (Medical = 20%; PCI = 19%; CABG = 6.3%; P < 0.05) and underwent fewer unscheduled procedures (Medical = 9.8%; PCI = 10.0%; CABG = 0.0%; P < 0.02). Conclusions: The results of this multinational registry demonstrate that hospital mortality in patients who undergo staged percutaneous revascularization of multivessel coronary disease following primary PCI is very low. Patients undergoing CABG following primary PCI are hospitalized less frequently and undergo fewer unplanned catheter‐based procedures. © 2011 Wiley‐Liss, Inc.     

Five-year outcomes of surgical or percutaneous myocardial revascularization in diabetic patients

Background

The study compares five-year clinical outcomes of CABG vs PCI in a real world population of diabetic patients with multivessel coronary disease since it is not clear whether to prefer surgical or percutaneous revascularization.

Methods

Between July 2002 and December 2008, 2885 multivessel coronary diabetic patients underwent revascularization (1466 CABG and 1419 PCI) at hospitals in Emilia-Romagna Region, Italy and were followed for 1827 ± 617 days by record linkage of two clinical registries with the regional administrative database of hospital admissions and the mortality registry. Five-year incidences of MACCE (mortality, acute myocardial infarction [AMI], stroke, and repeat revascularization [TVR]) were assessed with Kaplan–Meier estimates, Cox proportional hazards regression and cumulative incidence functions of death and TVR, to evaluate the competing risk of AMI on death and TVR. The same analyses were applied to the propensity score matched subgroup of patients undergoing CABG or PCI with DES and with complete revascularization.

Results

PCI had higher mortality for all causes (HR: 1.8, 95% CI 1.4–2.2 p < 0.0001), AMI (HR: 3.3, 95% CI 2.4–4.6 p < 0.0001) and TVR (HR: 4.5, 95% CI 3.4–6.1 p < 0.0001). No significant differences emerged for stroke (HR: 0.8, 95% CI 0.5–1.2 p = 0.26).The higher incidence of AMI caused higher mortality in PCI group. Results did not change comparing CABG with PCI patients receiving complete revascularization or DES only.

Conclusions

Diabetics show a higher incidence of MACCE with PCI than with CABG: thus diabetes and its degree of control should be considered when choosing the type of revascularization.     

Results of percutaneous drug‐eluting stent implantation for unprotected left main coronary disease according to left ventricular systolic function

Objectives: We aimed to appraise the early and long‐term outcome after percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) in patients with unprotected left main disease (ULM) and left ventricular systolic dysfunction (LVD). Background: PCI with DES has being performed with increasing frequency in subjects with ULM and LVD, but few specific data are available. Setting and Patients: We identified patients undergoing PCI with DES for ULM at our Center and distinguished those with ejection fraction (EF) >50% from those with 40% <EF ≤50% and those with EF ≤40%. The primary end‐point was the rate of major adverse cerebro‐cardiovascular events (MACCE, ie death, myocardial infarction [MI], stroke, repeat PCI or bypass surgery). Results: A total of 197 patients were included, 57.4% with EF >50%, 32.0% with 40% <EF ≤50%, and 10.6% with EF ≤40%. In‐hospital mortality was significantly higher in those with EF ≤40% (9.5% vs. 0 and 3.2%, P < 0.001). A total of 96% patients were followed for 23 ± 14 months, yielding a MACCE rate of 44.2% (41.6% in those with EF >50%, 41.6% in those with 40% <EF ≤50%, and 61.9% in those with EF ≤40%, P = 0.4). Specifically, death occurred in 2.7%, 7.9%, and 28.6% (P < 0.001), cardiac death in 1.8%, 4.8%, and 23.8% (P = 0.001), MI in 8.0%, 7.9% and 0 (P = 0.4), and TVR in 15.9%, 11.1% and 33.3% (P = 0.6). Conclusion: Systolic ventricular dysfunction is highly correlated with in‐hospital and long term death rates in patients undergoing PCI with DES for ULM disease. However it does not confer an increased risk of nonfatal adverse events or stent thrombosis. © 2009 Wiley‐Liss, Inc.     

Patient preferences for coronary artery bypass graft surgery or percutaneous intervention in multivessel coronary artery disease

Objectives: Determine if patients prefer multivessel percutaneous coronary intervention (mv‐PCI) over coronary artery bypass graft surgery (CABG) for treatment of symptomatic multivessel coronary artery disease (mv‐CAD) despite high 1‐year risk. Background: Patient risk perception and preference for CABG or mv‐PCI to treat medically refractory mv‐CAD are poorly understood. We hypothesize that patients prefer mv‐PCI instead of CABG even when quoted high mv‐PCI risk. Methods: 585 patients and 31 physicians were presented standardized questionnaires with a hypothetical scenario describing chest pain and medically refractory mv‐CAD. CABG or mv‐PCI was presented as treatment options. Risk scenarios included variable 1‐year risks of death, stroke, and repeat procedures for mv‐PCI and fixed risks for CABG. Participants indicated their preference of revascularization method based on the presented risks. We calculated the odds that patients or physicians would favor mv‐PCI over CABG across a range of quoted risks of death, stroke, and repeat procedures. Results: For nearly all quoted risks, patients preferred mv‐PCI over CABG, even when the risk of death was double the risk with CABG or the risk of repeat procedures was more than three times that for CABG (P < 0.0001). Compared to patients, physicians chose mv‐PCI less often than CABG as the risk of death and repeat procedures increased (P < 0.001 and P = 0.004, respectively). Conclusion: Patients favor mv‐PCI over CABG to treat mv‐CAD, even if 1‐year risks of death and repeat procedures far exceed risk with CABG. Physicians are more influenced by actual risk and prefer mv‐PCI less than patients despite similarly quoted 1‐year risks. © 2013 Wiley Periodicals, Inc.     

Comparison of Coronary Artery Bypass Grafting and Drug-Eluting Stents in Patients with Left Main Coronary Artery Disease and Chronic Kidney Disease: A Systematic Review and Meta-Analysis

BackgroundTreatment of left main coronary artery disease (LMCAD) in patients with chronic kidney disease (CKD) with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. Therefore, we performed a meta-analysis to evaluate the optimal choice of therapy when treating LMCAD in patients with CKD.MethodWe performed an electronic database search of Pubmed, Embase, and Cochrane Library for all studies that compared PCI with CABG when treating LMCAD in the setting of CKD. Major adverse cardiac and cerebrovascular events (MACCE) were the primary outcome. Secondary outcomes included myocardial infarction (MI), cerebrovascular events, all-cause mortality, and repeat revascularization.ResultsOur analysis included 5 studies (2 randomized controlled trial and 3 retrospective) representing a total of 1212 patients. Mean follow up was 3.4 ± 1.3 years. Our study demonstrated a significant reduction in MACCE for patients treated with CABG compared with PCI (odd ratio [OR] 0.72; 95% confidence interval [CI] 0.55–0.95, P = 0.02, I² = 0%). We also found a significant reduction in both MI (OR 0.55; 95% CI 0.34–0.87; P = 0.01; I² = 0%) and repeat revascularization (OR 0.22; 95% CI 0.10–0.51; P < 0.001, I² = 63%) in the CABG group. However, CABG was associated with increased risks of cerebrovascular disease events compared with PCI (OR 2.04; 95% CI 1.02–4.08; P = 0.04, I² = 0%).ConclusionIn patients with CKD requiring LMCAD intervention, CABG is associated with a lower risk of MACCE, MI, and repeat revascularization, however it was associated with an increased risk of cerebrovascular accidents when compared to patients who received PCI therapy. Further RCTs with sufficient power are required to confirm these findings.     

Urgent Revascularization Strategies in Patients With Diabetes Mellitus and Acute Coronary Syndrome

The prevalence of diabetes mellitus (DM) is rising globally and in Canada. Besides being a risk factor for the development of coronary artery disease, DM is also a marker of poor prognosis in patients with acute coronary syndrome (ACS), increasing the risks for ischemic and bleeding complications. Patients with DM have a high prevalence of multivessel coronary artery disease (MVD) and robust evidence has supported coronary artery bypass surgery (CABG) as the optimal revascularization strategy in the setting of stable ischemic heart disease. In the acute scenario, particularly in patients with non–ST-segment elevation (NSTE) ACS (NSTE-ACS), there are many uncertainties regarding the best revascularization strategy. Most guidelines suggest an invasive and timely approach (that is, performing coronary catheterization within 72 hours after the onset of the NSTE-ACS) and make recommendations about choosing between percutaneous coronary intervention (PCI) or CABG on the basis of data for patients with stable ischemic heart disease. Recent observational and subgroup analyses suggest that CABG might be the preferential method of revascularization for patients with DM and MVD also in the NSTE-ACS setting; however, dedicated randomized clinical trials are lacking. Finally, in patients who present with an ST-segment elevation myocardial infarction, the initial revascularization method of choice is generally PCI, instead of fibrinolysis or CABG, and DM status most often does not influence this decision. The management of residual MVD after primary PCI for ST-segment elevation myocardial infarction, however, remains controversial.     

Safety and effectiveness of drug eluting stent in patients with ST elevation myocardial infarction undergoing primary angioplasty

Background : Drug eluting stents (DES) have recently been proven to further reduce restenosis and revascularization rate in comparison to bare metal stents in elective procedures. Most early DES trials did not include patients undergoing primary percutaneous coronary intervention (PCI) for ST‐segment elevation MI, because these patients tend to have lower restenosis rates than other patient groups and delayed endothelization of these stents raises concern about a possible increase of thrombotic complications in the setting of STEMI. Aim : To confirm the safety and effectiveness of DES in patients with STEMI in a real‐world scenario. Methods : From January 2004 to December 2006, clinical and angiographic data of 370 patients with STEMI treated with primary PCI have been analyzed. Patients were retrospectively followed for the occurrence of major adverse cardiac events (MACE): death, reinfarction and target vessel revascularization (TVR). Results : Overall, 120 patients received DES (32%, DES group) and 250 received bare metal stents (68%, BMS group) in the infarct related artery. Compared with the BMS group, DES patients were younger, (mean age 56 ± 12 vs. 65 ± 10; P < 0.001) had more often diabetes mellitus (47% vs. 14% P < 0.001), anterior localization (65% vs. 45%; P < 0.0011) and less cardiogenic shock at admission (4% vs. 7%; P < 0.001). The angiographic characteristics in the DES group showed longer lesions (23 mm vs. 19 mm) and smaller diameter of vessels (2.5 mm vs. 3.0 mm). After a median follow‐up of 24 ± 9 months, there was no significant difference in the rate of stent thrombosis (1.6% in the DES group vs. 1.2% in the BMS group, P = ns). The incidence of MACE was significantly lower in the DES group compared with the BMS group (HR 0.56 [95% CI: 0.3–0.8]; P = 0.01), principally due to the lower rate of TVR (HR 0.41 [95% CI: 0.2–0.85]; P = 0.01). Conclusions : Utilization of DES in the setting of primary PCI for STEMI, in our “real world,” was safe and improved the 3‐year clinical outcome compared with BMS reducing the need of TVR. © 2008 Wiley‐Liss, Inc.     

Comparison of three treatment strategies for patients with triple‐vessel coronary disease and left ventricular dysfunction

Introduction

Current guidelines recommend coronary artery bypass grafting (CABG) for patients with multivessel coronary disease and left ventricular (LV) dysfunction. However, some patients undergo percutaneous coronary intervention (PCI) or solely medical therapy (MT) in actual practice. The comparison of long‐term outcomes of these three treatment strategies in real world is unclear.

Methods

A total of 699 consecutive patients in a single centre from 2004 to 2011 who had TVD and LV ejection fraction ≤40%, no prior PCI or CABG and had completed a median 6.2‐year follow‐up were evaluated. The primary endpoint was all‐cause death. The secondary endpoints included cardiac death, major adverse cardiovascular and cerebrovascular events (MACCE; composite of all‐cause death, myocardial infarction, repeat revascularization, or stroke), and the individual components of the composite endpoint.

Results

One hundred forty‐two patients (20.3%) underwent PCI, 201 (28.8%) underwent CABG while 356 (50.9%) received MT alone. MT alone was associated with the worst survival (P < 0.001). Compared with PCI, CABG was associated with a similar risk of all‐cause death (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.52‐1.41; P = 0.54) but lower risks of cardiac death (HR, 0.47; 95%CI, 0.25‐0.91; P = 0.03), repeat revascularization (HR, 0.29; 95%CI, 0.10‐0.85; P = 0.02), and MACCE (HR, 0.63; 95%CI, 0.43‐0.93; P = 0.02).

Conclusions

For patients with TVD and LV dysfunction, both CABG and PCI were associated with a lower risk of mortality compared with MT alone. Compared with PCI, CABG has a lower risk of cardiac death, repeat revascularization, and MACCE.

     

药物洗脱支架与冠状动脉旁路移植术治疗无保护左主干病变的临床疗效对比

目的:评估药物洗脱支架(DES)置入与冠状动脉旁路移植术(CABG)治疗无保护左主干病变的临床疗效。方法:分析2003-10-2010-09期间行血运重建的282例无保护左主干患者的临床资料,其中接受DES者143例(DES组),接受CABG者139例(CABG组),比较2组住院期和随访期心脑血管不良事件(死亡、非致死性心肌梗死、脑卒中和再次血运重建,即MACCE)的发生情况。结果:DES组手术成功率为100%,住院期间1例发生非致死性心肌梗死,无一例死亡、脑血管意外或需再次血运重建;CABG组手术成功率为95.7%,住院期间有1例发生非致死性急性心肌梗死,无一例需再次血运重建,共有6例死亡;CABG组住院期死亡率明显高于DES组(4.3%∶0,P<0.05),住院期CABG组总MACCE发生率也明显高于DES组(5.0%∶0.7%,P<0.05);随访期平均(17±8)个月,DES组临床心绞痛复发率和再次血运重建率较CABG组有增高趋势(7.8%∶2.7%,7.0%∶1.8%),但差异无统计学意义,其总MACCE发生率显著高于CABG组(14.8%∶7.1%,P<0.05);剔除新发病变及病变进展病例后,2组总MACCE发生率(7.8%∶7.1%)差异无统计学意义。结论:DES治疗无保护左主干病变安全和有效,可以作为CABG的一种替代治疗手段。     

Revascularization in complex multivessel coronary artery disease after FREEDOM

Diabetes mellitus is a highly prevalent metabolic disorder frequently associated with the development of coronary atherosclerosis. Myocardial revascularization assumes a central role in the treatment of diabetic patients with coronary artery disease. Although coronary artery bypass grafting (CABG) is in principle the revascularization modality of choice in diabetic patients with complex, multivessel disease, percutaneous coronary interventions (PCI) using new-generation drug-eluting stents (DES) remain a valuable treatment option for properly selected diabetic patients. Defining the appropriate revascularization strategy is often a challenging task that requires tailored approaches, accounting for individual patient surgical risk, anatomical configurations, and the technical feasibility of each procedure in addition to careful judgment of the possible benefits and risks inherent to PCI and CABG. Evidence is building that advances in DES technology may mitigate at least in part some of the adverse vascular effects of diabetes; whether this may translate to PCI outcomes comparable with those achieved by CABG is under investigation in randomized trials currently underway. This review article summarizes the indications for myocardial revascularization across the spectrum of clinical presentations and critically discusses current evidence and future perspectives regarding the value of each revascularization mode (CABG vs. PCI) in patients with diabetes.     

The Association of Previous Revascularization With In-Hospital Outcomes in Acute Myocardial Infarction Patients: Results From the National Cardiovascular Data Registry

ObjectivesThe aim of this study was to compare outcomes of ST-segment elevation myocardial infarction (STEMI) patients with a history of coronary artery bypass graft surgery (CABG), previous percutaneous coronary intervention (PCI), or no previous revascularization undergoing primary PCI.BackgroundLimited data exist regarding door-to-balloon times and clinical outcomes of STEMI patients with a history of CABG or PCI undergoing primary PCI.MethodsWe examined 15,628 STEMI patients who underwent primary PCI at 297 sites in the United States. We used multivariable logistic regression analyses to compare door-to-balloon time delays >90 min and in-hospital major adverse cardiovascular or cerebrovascular events (MACCE).ResultsPatients with previous CABG were significantly older and more likely to have multiple comorbidities (p < 0.0001). Previous CABG was associated with a lower likelihood of a door-to-balloon time ≤90 min compared with patients with no previous revascularization. However, no significant differences in door-to-balloon times were noted between patients with previous PCI and those without previous revascularization. The unadjusted MACCE risk was significantly higher in patients with a history of CABG compared with patients without previous revascularization (odds ratio: 1.68, 95% confidence interval: 1.23 to 2.31). However, after multivariable risk adjustment, there were no significant differences in MACCE risk between the 2 groups. No significant differences in in-hospital outcomes were seen in patients with a previous PCI and those without previous revascularization.ConclusionsIn a large cohort of STEMI patients undergoing primary PCI, patients with previous CABG were more likely to have reperfusion delays, yet risk-adjusted, in-hospital outcomes were similar to those without previous revascularization. No significant differences in reperfusion timeliness and in-hospital outcomes were seen in patients with a history of PCI compared with patients without previous revascularization.