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Long-term Outcomes in Patients With Severely Reduced Left Ventricular Ejection Fraction Undergoing Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting
Louise Y. Sun, MD, SM; Mario Gaudino, MD; Robert J. Chen, MD; Anan Bader Eddeen, MSc; Marc Ruel, MD, MPH
Summary By: Adriana C. Mares - Founder & President, The Institute of Cardiology at El Paso
Overall Study Question:
What is the difference of long-term outcomes in patients with coronary artery disease (CAD) and reduced left ventricular ejection fraction (LVEF) undergoing revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)?
Study Summary:
From October 1, 2008 to December 31, 2016, investigators conducted a population-based cohort study in Ontario, Canada of 12,113 patients between 40 and 84 years of age who underwent PCI or CABG with LVEFs < 35% and left anterior descending (LAD), left main, or multivessel coronary artery disease (with or without LAD involvement). Exclusion criteria consisted of concomitant performance of previous CABG, metastatic cancer, dialysis, CABG and PCI on the same day, and emergency revascularization occurred within 24 hours of a myocardial infarction (MI). Data analysis was performed from June 2, 2018 to December 28, 2018. The primary outcome was all-cause mortality. Secondary outcomes were death from cardiovascular disease, major adverse cardiovascular events (MACE; defined as stroke, subsequent revascularization, and hospitalization for MI or heart failure [HF]), and each of the individual MACE (1,2).
The median follow-up was 5.2 years (interquartile range, 5.0-5.3) and, of 12, 113 patients, the mean [standard deviation] age were 64.8 [11.0] years for the PCI group and 65.6 [9.7] years for the CABG group. To balance the study groups and make comparisons, of 5084 (72.5%) male for the PCI group and 4229 (82.9%) male for the PCI group, 7013 (57.9%) underwent PCI and 5100 (42.1%) underwent CABG . Then, were propensity score matched on 30 baseline characteristics, resulting in 2,397 patients undergoing PCI and 2,397 patients undergoing CABG (2).
Patients who underwent PCI had significantly higher rates of mortality (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.3-1.7), death from cardiovascular disease (HR, 1.4; 95% CI, 1.1-1.6), MACE (HR, 2.0; 95% CI, 1.9-2.2), subsequent revascularization (HR, 3.7; 95% CI, 3.2-4.3), and hospitalization for MI (HR, 3.2; 95% CI, 2.6-3.8) and HF (HR, 1.5; 95% CI, 1.3-1.6) compared with matched patients who underwent CABG. The authors concluded that, during long-term follow-up, patients with CAD and severely reduced LVEF who underwent PCI compared to those who underwent CABG had significantly higher rates of mortality and MACE. Notably, this trend was consistent across subgroups regardless of the presence of diabetes and even more, in patients with multivessel disease (2).
My Insights:
Through my experience of attending conferences discussing the ISCHEMIA trial, it has certainly generated extensive and vigorous discussion in multiple settings to determine the best management strategy for high-risk patients with stable ischemic heart disease. But, even before the publication of the ISCHEMIA trial, there is an amplitude of research on the differences in clinical outcomes between CABG and PCI. Knowing that it is a persistent and controversial issue among clinicians who perform medical and surgical therapy, perhaps there may be specific benefits for different groups of patients who undergo one revascularization technique over the other. For example, stent placement could be a limiting factor with PCI, since revascularization of longer epicardial segments is best accomplished with CABG (2). Furthermore, in patients undergoing PCI, the effectiveness and safety with the drug-eluting stent (DES) and metal stents can vary; however, as reported by Sun and his colleagues' mortality rates were higher among patients undergoing PCI, regardless of stent.
Finally, the recommendations for the treatment of patients with severe reduced LVEF and CAD vary between European and US guidelines. The European guidelines recommend revascularization, with a preference for CABG over PCI, in patients with reduced left ventricular ejection fraction (LVEF) and multivessel CAD (3). The US guidelines favor the use of CABG but do not provide recommendations about PCI, (4) stating that “the choice of revascularization … is best based on clinical variables, … magnitude of LV systolic dysfunction, patient preferences, clinical judgment, and consultation between the interventional cardiologist and the cardiac surgeon”(4). Overall, this study supports the preferred revascularization strategy of both guidelines, CABG. However, in my opinion, there are a wide variety of factors related to the vessel dimension, plaque burden, lesion length, equipment requirements, operator technique, among many others that could influence decision making and challenge current recommendations.
Long-term Outcomes in Patients With Severely Reduced Left Ventricular Ejection Fraction Undergoing Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting
Louise Y. Sun, MD, SM; Mario Gaudino, MD; Robert J. Chen, MD; Anan Bader Eddeen, MSc; Marc Ruel, MD, MPH
Summary By: Adriana C. Mares - Founder & President, The Institute of Cardiology at El Paso
Overall Study Question:
What is the difference of long-term outcomes in patients with coronary artery disease (CAD) and reduced left ventricular ejection fraction (LVEF) undergoing revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)?
Study Summary:
From October 1, 2008 to December 31, 2016, investigators conducted a population-based cohort study in Ontario, Canada of 12,113 patients between 40 and 84 years of age who underwent PCI or CABG with LVEFs < 35% and left anterior descending (LAD), left main, or multivessel coronary artery disease (with or without LAD involvement). Exclusion criteria consisted of concomitant performance of previous CABG, metastatic cancer, dialysis, CABG and PCI on the same day, and emergency revascularization occurred within 24 hours of a myocardial infarction (MI). Data analysis was performed from June 2, 2018 to December 28, 2018. The primary outcome was all-cause mortality. Secondary outcomes were death from cardiovascular disease, major adverse cardiovascular events (MACE; defined as stroke, subsequent revascularization, and hospitalization for MI or heart failure [HF]), and each of the individual MACE (1,2).
The median follow-up was 5.2 years (interquartile range, 5.0-5.3) and, of 12, 113 patients, the mean [standard deviation] age were 64.8 [11.0] years for the PCI group and 65.6 [9.7] years for the CABG group. To balance the study groups and make comparisons, of 5084 (72.5%) male for the PCI group and 4229 (82.9%) male for the PCI group, 7013 (57.9%) underwent PCI and 5100 (42.1%) underwent CABG . Then, were propensity score matched on 30 baseline characteristics, resulting in 2,397 patients undergoing PCI and 2,397 patients undergoing CABG (2).
Patients who underwent PCI had significantly higher rates of mortality (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.3-1.7), death from cardiovascular disease (HR, 1.4; 95% CI, 1.1-1.6), MACE (HR, 2.0; 95% CI, 1.9-2.2), subsequent revascularization (HR, 3.7; 95% CI, 3.2-4.3), and hospitalization for MI (HR, 3.2; 95% CI, 2.6-3.8) and HF (HR, 1.5; 95% CI, 1.3-1.6) compared with matched patients who underwent CABG. The authors concluded that, during long-term follow-up, patients with CAD and severely reduced LVEF who underwent PCI compared to those who underwent CABG had significantly higher rates of mortality and MACE. Notably, this trend was consistent across subgroups regardless of the presence of diabetes and even more, in patients with multivessel disease (2).
My Insights:
Through my experience of attending conferences discussing the ISCHEMIA trial, it has certainly generated extensive and vigorous discussion in multiple settings to determine the best management strategy for high-risk patients with stable ischemic heart disease. But, even before the publication of the ISCHEMIA trial, there is an amplitude of research on the differences in clinical outcomes between CABG and PCI. Knowing that it is a persistent and controversial issue among clinicians who perform medical and surgical therapy, perhaps there may be specific benefits for different groups of patients who undergo one revascularization technique over the other. For example, stent placement could be a limiting factor with PCI, since revascularization of longer epicardial segments is best accomplished with CABG (2). Furthermore, in patients undergoing PCI, the effectiveness and safety with the drug-eluting stent (DES) and metal stents can vary; however, as reported by Sun and his colleagues' mortality rates were higher among patients undergoing PCI, regardless of stent.
Finally, the recommendations for the treatment of patients with severe reduced LVEF and CAD vary between European and US guidelines. The European guidelines recommend revascularization, with a preference for CABG over PCI, in patients with reduced left ventricular ejection fraction (LVEF) and multivessel CAD (3). The US guidelines favor the use of CABG but do not provide recommendations about PCI, (4) stating that “the choice of revascularization … is best based on clinical variables, … magnitude of LV systolic dysfunction, patient preferences, clinical judgment, and consultation between the interventional cardiologist and the cardiac surgeon”(4). Overall, this study supports the preferred revascularization strategy of both guidelines, CABG. However, in my opinion, there are a wide variety of factors related to the vessel dimension, plaque burden, lesion length, equipment requirements, operator technique, among many others that could influence decision making and challenge current recommendations.
References
1. Mukherjee DP. Outcomes in Patients With Reduced LVEF After PCI vs. CABG. https://www.acc.org/latest-in-cardiology/journal-scans/2020/04/08/13/21/long-term-outcomes-in-patients-with-severely. Published April 08, 2020. Accessed April 10, 2020.
2. Sun LY, Gaudino M, Chen RJ, Bader Eddeen A, Ruel M. Long-term Outcomes in Patients With Severely Reduced Left Ventricular Ejection Fraction Undergoing Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting. JAMA Cardiol. Published online April 08, 2020. doi:10.1001/jamacardio.2020.0239
3. Neumann FJ, Sousa-Uva M, Ahlsson A, et al; ESC Scientific Document Group. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165. doi:10.1093/eurheartj/ ehy394
4. Fihn SD, Gardin JM, Abrams J, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; American College of Physicians; American Association for Thoracic Surgery; Preventive Cardiovascular Nurses Association; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012;60(24):e44-e164. doi:10.1016/j.jacc.2012.07.013
Back to other Article Summaries
1. Mukherjee DP. Outcomes in Patients With Reduced LVEF After PCI vs. CABG. https://www.acc.org/latest-in-cardiology/journal-scans/2020/04/08/13/21/long-term-outcomes-in-patients-with-severely. Published April 08, 2020. Accessed April 10, 2020.
2. Sun LY, Gaudino M, Chen RJ, Bader Eddeen A, Ruel M. Long-term Outcomes in Patients With Severely Reduced Left Ventricular Ejection Fraction Undergoing Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting. JAMA Cardiol. Published online April 08, 2020. doi:10.1001/jamacardio.2020.0239
3. Neumann FJ, Sousa-Uva M, Ahlsson A, et al; ESC Scientific Document Group. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165. doi:10.1093/eurheartj/ ehy394
4. Fihn SD, Gardin JM, Abrams J, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; American College of Physicians; American Association for Thoracic Surgery; Preventive Cardiovascular Nurses Association; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012;60(24):e44-e164. doi:10.1016/j.jacc.2012.07.013
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