Nonemergent target-vessel revascularization (TLR) poses a substantial, independent late mortality risk, even in the era of drug-eluting stents (DES), at least partly because of its risk for subsequent myocardial infarction (MI), conclude researchers.
The post-TVR mortality risk in their 21-trial meta-analysis was significant even after exclusion of patients developing an MI during the average 2.5-year follow-up.
It’s a “general perception” that revascularization for restenosis after percutaneous coronary intervention (PCI) is very low risk and that it doesn’t predict a poor long-term outcome, Gregg W Stone, MD, Columbia University Medical Center, New York City, told theheart.org | Medscape Cardiology.
“What this paper points out is that it’s not an entirely benign procedure, and it does have negative prognostic implications for the patient,” he said, referring to the report published April 18 in JACC: Cardiovascular Interventions with Tullio Palmerini, MD, Policlinico Sant’Orsola-Malpighi, Bologna, Italy, as lead author and Stone as senior author.
How TLR, which could be PCI or coronary bypass surgery (CABG), was related to mortality over the follow-up, beyond its partial association with MI, wasn’t answered by the analysis. Perhaps the TLR procedure disrupts coronary plaques beyond the target segment, “which then go on and cause a myocardial infarction,” Stone speculated.
“Or it just could be a confounder for patients who have more aggressive disease and are more likely to develop myocardial infarctions,” he said.
“Patients requiring repeat revascularization have a higher disease burden or faster disease progression, and that might be driving the higher mortality, in part,” agreed Deepak L Bhatt, MD, MPH, Brigham and Women’s Hospital, Boston, Massachusetts, who was not involved in the analysis.
Alternatively, “it could in part be the additional stents and additional risk of stent thrombosis, or even the attendant bleeding risks from protracted dual-antiplatelet therapy,” he said in an interview.
“The bottom line is that efforts to decrease TLR rates further are warranted, even in the era of second-generation DES,” said Bhatt. “Interventionalists tend to downplay the higher rate of repeat revascularization with PCI vs CABG, but surgeons think that is a big advantage to CABG — that the endpoint of repeat revascularization isn’t as trivial as we sometimes make it sound. And they might be on to something.”
The analysis includes randomized trials of both bare-metal stents and DES, observes an accompanying editorial by Harold L Dauerman, MD, University of Vermont, Burlington. The post-TLR mortality risk was probably higher in those earlier trials than after widespread use of DES, so it may be hard to further reduce it further compared with contemporary levels.
Moreover, there are many predictors of post-TLR mortality, “and TLR is not close to being the most powerful one,” notes Dauerman. “Progression of non-culprit disease, subsequent myocardial infarction and stent thrombosis are likely the main determinants of longer term death.”
On the other hand, the analysis probably “underemphasizes” the magnitude of TLR as a predictor of risk, Stone said, “because we excluded all the complicated TLR procedures.”
Indeed, the analysis excluded TLR cases that were “emergent or complicated,” including any that were in response to an acute MI or other acute coronary syndrome, and those that themselves were complicated by periprocedural MI.
“Similarly, we excluded patients who died the same day as or the day after the revascularization procedure,” notes the study authors.
The meta-analysis combined patient-level data from 21 randomized comparisons of DES vs bare-metal stents or other DES. Over a median follow-up of 37 months, 7.2% of the 32,524 patients under went a nonemergent, uncomplicated TLR.
Their hazard ratio (HR) for later mortality was 1.23 (95% CI, 1.04 – 1.45; P = .02) for TLR vs non-TLR patients. The HR for non–procedural-related MI after TLR was 3.82 (95% CI, 2.44 – 5.99; P < .0001). The analyses adjusted for age, sex, diabetes, previous MI, previous PCI or CABG, postprocedure MI, stent thrombosis, repeat revascularization, and study contributing to the meta-analysis.
But it couldn’t adjust for many factors that could have been confounders, the report notes, notably target-lesion and target-vessel anatomic features, number of stents, variations in access site or staging of procedures, or medication use.
The current findings, Bhatt said, “may be part of the reason CABG is superior to PCI for mortality in complex lesions subsets, such as diabetic patients with extensive multivessel disease.”
Palmerini discloses receiving personal fees from Abbott and grants from Eli Lilly. Stone said he has no relevant disclosures. The other coauthors report they “have nothing to disclose.” Dauerman reports consulting for Medtronic, Edwards, and Boston Scientific and receiving research grants from Boston Scientific, Edwards, and Medtronic. Bhatt has reported numerous relationships with institutions and industry and has served on a continuing medical education steering committee for WebMD.
JACC: Cardiovasc Interv. Published online April 18, 2108. Abstract, Editorial
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