CHICAGO — Incomplete revascularization (IR) in patients with multivessel coronary disease undergoing percutaneous coronary intervention (PCI), already associated with increased mortality risk, predicts even greater risk if the vessels not revascularized have certain anatomic features, suggests an observational cohort study.[1]
Dr Edward L Hannan
Features that heightened 3-year PCI mortality in the analysis, based on New York Percutaneous Coronary Interventions Reporting System data, included an IR stenosis of 90% or greater, IR in at least two coronary arteries, and IR of the proximal left anterior descending (LAD) coronary artery.
“Not all IR is the same. It is wise to avoid IR if possible, and even better to avoid some types,” lead author, Dr Edward L Hannan (State University of New York, University at Albany, Rensselaer), told theheart.org | Medscape Cardiology.
“Although interventionalists are undoubtedly aware of the dangers of IR, this study emphasizes that it is especially important to try to avoid it, and consider CR [complete revascularization] or even CABG [coronary artery bypass graft] surgery for certain types of IR,” said Hannan, lead author on the report, published December 27, 2017, in JAMA Cardiology.
The study “adds to the literature, demonstrating that outcome is not only dependent on whether revascularization is complete but also on how complete the revascularization is,” writes Dr William S Weintraub (MedStar Washington Hospital Center, Washington, DC) in an accompanying commentary.[2]
The analysis included 41,639 New York residents with multivessel disease who underwent PCI in New York state from 2010 through 2012.
They were categorized by whether their procedure was in the setting of ST-segment-elevation myocardial infarction (STEMI) or acute coronary syndrome, or stable ischemic heart disease in the absence of STEMI.
“We compared 3-year mortality in patients undergoing PCI with IR that is potentially more severe than typical IR with CR patients and other IR patients,” Hannan said.
“Since the first group may be sicker in other respects—older, more comorbidities—we statistically adjusted for these differences or variables when comparing the results,” Hannan explained.
Bad Actors Identified
Incomplete revascularization was very common, occurring in 78% of patients with STEMI and in 71% of patients with no STEMI.
Of the patients with STEMI, 34% had an IR vessel with a stenosis of 90% or greater, 24% had two or more major epicardial IR vessels, and nearly 10% had an IR proximal LAD.
Of patients without STEMI, nearly one third had at least one IR vessel with 90% or greater stenosis, one fifth had two or more IR vessels, and 7% had an IR proximal LAD.
For all three high-risk coronary anatomic features, mortality was significantly higher for patients getting IR compared with CR at a median follow-up of 3.4 years.
Table. Mortality Hazard Ratio s for IR b y Vessel Characteristics a
| Vessel Characteristic | STEMI: HR (95% CI) | Non-STEMI: HR (95% CI) |
|---|---|---|
| ≥90% stenosis | 1.16 (0.99–1.37) | 1.15 (1.07–1.24) |
| IR in ≥2 vessels | 1.35 (1.15–1.59) | 1.17 (1.09–1.59) |
| Proximal LAD IR | 1.31 (1.04–1.64) | 1.11 (1.01–1.23) |
| aCompared with CR, adjusted for age, body mass index, ejection fraction, hemodynamic instability, congestive heart failure, malignant ventricular arrhythmia, chronic obstructive pulmonary disease, diabetes, and renal failure. CI = confidence interval; HR = hazard ratio. | ||
Weintraub urges cautious interpretation of the findings and questions the idea that outcomes will improve if more patients get PCI with CR. The current analysis, for example, could not control for every possible confounder.
“Examples of possible confounders in this patient population would be diffuseness of disease, severity of left ventricular dysfunction, and the degree of frailty that led to incomplete revascularization. Of these variables, only left ventricular function, assessed by history of heart failure and ejection fraction, was measured,” he writes.
“There are certainly reasons that incomplete revascularization is performed…. It is not clear that urging operators to more completely revascularize will lead to better outcomes.”
It will be hard to carry out randomized trials of revascularization completeness “because of issues related both to anatomy limiting complete revascularization and lack of equipoise where complete revascularization can readily be carried out,” according to Weintraub.
“Thus, we will continue to learn more from observational studies. In this regard, the article by Hannan et al is a seminal contribution.”
The study was partially funded from the New York State Department of Health. Hannan and Weintraub have disclosed no relevant financial relationships; disclosures for the other authors are in the report.
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