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Vol 26, No 2 (2019)
Original articles — Clinical cardiology
Published online: 2017-09-28
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Long-term outcomes of patients with multivessel coronary artery disease presenting non-ST-segment elevation acute coronary syndromes

Piotr Desperak, Michał Hawranek, Paweł Gąsior, Aneta Desperak, Andrzej Lekston, Mariusz Gąsior
DOI: 10.5603/CJ.a2017.0110
·
Pubmed: 28980282
·
Cardiol J 2019;26(2):157-168.

open access

Vol 26, No 2 (2019)
Original articles — Clinical cardiology
Published online: 2017-09-28

Abstract

Background: There is paucity of data concerning the optimal revascularization in patients with mul- tivessel coronary artery disease (CAD) presenting non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The aim was to evaluate long-term outcomes of patients with multivessel CAD presenting NSTE-ACS depending on the management after coronary angiography.

Methods: 3,166 patients with NSTE-ACS hospitalized between 2006 and 2014 were screened. After ex- clusions, 1,342 patients were enrolled with multivessel CAD and were divided depending on their man- agement after coronary angiography; the medical-only therapy group (n = 91), the percutaneous coronary intervention (PCI) group (n = 1,122), the coronary artery bypass grafting (CABG) group (n = 129). Propensity scores matching was used to adjust for differences in patient baseline characteristics. 

Results: After propensity score analysis, 273 well-matched patients were chosen. Both before and after matching, patients treated with a medical-only therapy were burdened with the highest percentage of 24-month all-cause death and non-fatal MI in comparison to PCI and CABG groups, respectively. In the CABG group, ACS-driven revascularization rate was lowest. In the overall population, PCI (HR 0.33; 95% CI 0.20–0.53; p < 0.0001) and CABG (HR 0.54; 95% CI 0.31–0.93; p = 0.028) were independent factors associated with favorable 24-month prognosis. However, in a matched population only PCI was an independent predictor of long-term prognosis with a 63% decrease of 24-month mortal- ity (HR 0.37; 95% CI 0.19–0.69; p = 0.0020).

Conclusions: In patients with multivessel CAD presenting with NSTE-ACS, medical-only man- agement is related with adverse long-term prognosis in contrast to revascularization, which reduces 24-month mortality, especially among patients undergoing percutaneous intervention. Performance of PCI is an independent factor for improving long-term prognosis. 

Abstract

Background: There is paucity of data concerning the optimal revascularization in patients with mul- tivessel coronary artery disease (CAD) presenting non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The aim was to evaluate long-term outcomes of patients with multivessel CAD presenting NSTE-ACS depending on the management after coronary angiography.

Methods: 3,166 patients with NSTE-ACS hospitalized between 2006 and 2014 were screened. After ex- clusions, 1,342 patients were enrolled with multivessel CAD and were divided depending on their man- agement after coronary angiography; the medical-only therapy group (n = 91), the percutaneous coronary intervention (PCI) group (n = 1,122), the coronary artery bypass grafting (CABG) group (n = 129). Propensity scores matching was used to adjust for differences in patient baseline characteristics. 

Results: After propensity score analysis, 273 well-matched patients were chosen. Both before and after matching, patients treated with a medical-only therapy were burdened with the highest percentage of 24-month all-cause death and non-fatal MI in comparison to PCI and CABG groups, respectively. In the CABG group, ACS-driven revascularization rate was lowest. In the overall population, PCI (HR 0.33; 95% CI 0.20–0.53; p < 0.0001) and CABG (HR 0.54; 95% CI 0.31–0.93; p = 0.028) were independent factors associated with favorable 24-month prognosis. However, in a matched population only PCI was an independent predictor of long-term prognosis with a 63% decrease of 24-month mortal- ity (HR 0.37; 95% CI 0.19–0.69; p = 0.0020).

Conclusions: In patients with multivessel CAD presenting with NSTE-ACS, medical-only man- agement is related with adverse long-term prognosis in contrast to revascularization, which reduces 24-month mortality, especially among patients undergoing percutaneous intervention. Performance of PCI is an independent factor for improving long-term prognosis. 

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Keywords

non-ST-elevation myocardial infarction; percutaneous coronary intervention; coronary bypass grafts; multivessel coronary artery disease; long-term outcomes

About this article
Title

Long-term outcomes of patients with multivessel coronary artery disease presenting non-ST-segment elevation acute coronary syndromes

Journal

Cardiology Journal

Issue

Vol 26, No 2 (2019)

Pages

157-168

Published online

2017-09-28

DOI

10.5603/CJ.a2017.0110

Pubmed

28980282

Bibliographic record

Cardiol J 2019;26(2):157-168.

Keywords

non-ST-elevation myocardial infarction
percutaneous coronary intervention
coronary bypass grafts
multivessel coronary artery disease
long-term outcomes

Authors

Piotr Desperak
Michał Hawranek
Paweł Gąsior
Aneta Desperak
Andrzej Lekston
Mariusz Gąsior

References (39)
  1. Mehta SR, Granger CB, Boden WE, et al. TIMACS Investigators. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009; 360(21): 2165–2175.
  2. Thiele H, Rach J, Klein N, et al. LIPSIA-NSTEMI Trial Group. Optimal timing of invasive angiography in stable non-ST-elevation myocardial infarction: the Leipzig Immediate versus early and late PercutaneouS coronary Intervention triAl in NSTEMI (LIPSIA-NSTEMI Trial). Eur Heart J. 2012; 33(16): 2035–2043.
  3. Montalescot G, Bolognese L, Dudek D, et al. ACCOAST Investigators. Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. N Engl J Med. 2013; 369(11): 999–1010.
  4. Halim SA, Clare RM, Newby LK, et al. Frequency, clinical and angiographic characteristics, and outcomes of high-risk non-ST-segment elevation acute coronary syndromes patients with left circumflex culprit lesions. Int J Cardiol. 2016; 203: 708–713.
  5. Lansky AJ, Goto K, Cristea E, et al. Clinical and angiographic predictors of short- and long-term ischemic events in acute coronary syndromes: results from the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial. Circ Cardiovasc Interv. 2010; 3(4): 308–316.
  6. Beigel R, Matetzky S, Gavrielov-Yusim N, et al. ACSIS and ACSIS-PCI 2010 Investigators. Predictors of high-risk angiographic findings in patients with non-ST-segment elevation acute coronary syndrome. Catheter Cardiovasc Interv. 2014; 83(5): 677–683.
  7. Fox KAA, Clayton TC, Damman P, et al. FIR Collaboration. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol. 2010; 55(22): 2435–2445.
  8. Katritsis DG, Siontis GCM, Kastrati A, et al. Optimal timing of coronary angiography and potential intervention in non-ST-elevation acute coronary syndromes. Eur Heart J. 2011; 32(1): 32–40.
  9. Roffi M, Patrono C, Collet JP, et al. Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016; 37(3): 267–315.
  10. Amsterdam EA, Wenger NK, Brindis RG, et al. American College of Cardiology, American Heart Association Task Force on Practice Guidelines, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Clinical Chemistry. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 64(24): e139–e228.
  11. Qiao Y, Li W, Mohamed S, et al. A comparison of multivessel and culprit vessel percutaneous coronary intervention in non-ST-segment elevation acute coronary syndrome patients with multivessel disease: a meta-analysis. EuroIntervention. 2015; 11(5): 525–532.
  12. Jang JS, Jin HY, Seo JS, et al. Meta-analysis of multivessel versus culprit-only percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndrome and multivessel coronary disease. Am J Cardiol. 2015; 115(8): 1027–1032.
  13. Sardella G, Lucisano L, Garbo R, et al. Single-staged compared with multi-staged PCI in multivessel NSTEMI patients: The SMILE Trial. J Am Coll Cardiol. 2016; 67(3): 264–272.
  14. Ben-Gal Y, Moses J, Mehran R, et al. Surgical versus percutaneous revascularization for multivessel disease in patients with acute coronary syndromes. J Am Coll Cardiol Intv. 2010; 3(10): 1059–1067.
  15. Hamm CW, Bassand JP, Agewall S, et al. European Society of Cardiology. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011; 32(23): 2999–3054.
  16. Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J. 2007; 28(13): 1598–1660.
  17. Rickham PP. Human experimentation. Code of ethics of the world medical association. Declaration of Helsinki. Br Med J. 1964; 18: 177.
  18. Thygesen K, Alpert JS, White HD, et al. Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J. 2007; 28: 2525–2538.
  19. Windecker S, Kohl P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014; 35(37): 2541–2619.
  20. European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis. 2008; 25(5): 457–507.
  21. Mohr F, Morice MC, Kappetein A, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. The Lancet. 2013; 381(9867): 629–638.
  22. Hlatky MA, Boothroyd DB, Bravata DM, et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet. 2009; 373(9670): 1190–1197.
  23. Bravata DM, Gienger AL, McDonald KM, et al. Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery. Ann Intern Med. 2007; 147(10): 703–716.
  24. Solodky A, Behar S, Boyko V, et al. The outcome of coronary artery bypass grafting surgery among patients hospitalized with acute coronary syndrome: the Euro Heart Survey of acute coronary syndrome experience. Cardiology. 2005; 103(1): 44–47.
  25. Chen LY, Lennon RJ, Grantham JA, et al. In-hospital and long-term outcomes of multivessel percutaneous coronary revascularization after acute myocardial infarction. Am J Cardiol. 2005; 95(3): 349–354.
  26. Buszman PE, Buszman PP, Bochenek A, et al. Comparison of stenting and surgical revascularization strategy in non-ST elevation acute coronary syndromes and complex coronary artery disease (from the Milestone Registry). Am J Cardiol. 2014; 114(7): 979–987.
  27. Gierlotka M, Gąsior M, Wilczek K, et al. Temporal trends in the treatment and outcomes of patients With non-ST-segment elevation myocardial infarction in Poland from 2004-2010 (from the Polish Registry of Acute Coronary Syndromes). Am J Cardiol. 2012; 109(6): 779–786.
  28. de Winter RJ, Windhausen F, Cornel JH, et al. Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med. 2005; 353(11): 1095–1104.
  29. Williams B, Menon M, Satran D, et al. Patients with coronary artery disease not amenable to traditional revascularization: prevalence and 3-year mortality. Catheter Cardiovasc Interv. 2010; 75(6): 886–891.
  30. Bettinger N, Palmerini T, Caixeta A, et al. Risk stratification of patients undergoing medical therapy after coronary angiography. Eur Heart J. 2016; 37(40): 3103–3110.
  31. Palmerini T, Biondi-Zoccai G, Reggiani L, et al. Risk of Stroke With Coronary Artery Bypass Graft Surgery Compared With Percutaneous Coronary Intervention. J Am Coll Cardiol. 2012; 60(9): 798–805.
  32. Buszman PP, Bochenek A, Konkolewska M, et al. Early and long-term outcomes after surgical and percutaneous myocardial revascularization in patients with non-ST-elevation acute coronary syndromes and unprotected left main disease. J Invasive Cardiol. 2009; 21(11): 564–569.
  33. Zhao C, Wang X, Wu X, et al. Early and long-term outcomes after percutaneous coronary intervention of unprotected left main coronary disease with drug-eluting stents in patients with non-ST-elevation acute coronary syndrome. Can J Cardiol. 2011; 27(6): 743–748.
  34. Mennuni MG, Dangas GD, Mehran R, et al. Coronary Artery Bypass Surgery Compared With Percutaneous Coronary Intervention for Proximal Left Anterior Descending Artery Treatment in Patients With Acute Coronary Syndrome: Analysis From the ACUITY Trial. J Invasive Cardiol. 2015; 27(10): 468–473.
  35. Ben-Gal Y, Mohr R, Feit F, et al. Surgical versus percutaneous coronary revascularization for multivessel disease in diabetic patients with non-ST-segment-elevation acute coronary syndrome: analysis from the Acute Catheterization and Early Intervention Triage Strategy trial. Circ Cardiovasc Interv. 2015; 8(6).
  36. Vergallo R, Ren X, Yonetsu T, et al. Pancoronary plaque vulnerability in patients with acute coronary syndrome and ruptured culprit plaque: a 3-vessel optical coherence tomography study. Am Heart J. 2014; 167(1): 59–67.
  37. Palmerini T, Genereux P, Caixeta A, et al. Prognostic value of the SYNTAX score in patients with acute coronary syndromes undergoing percutaneous coronary intervention: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage StrategY) trial. J Am Coll Cardiol. 2011; 57(24): 2389–2397.
  38. Stone G, Sabik J, Serruys P, et al. Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease. N Engl J Med. 2016; 375(23): 2223–2235.
  39. Parikh SV, de Lemos JA, Jessen ME, et al. CRUSADE and ACTION Registry-GWTG Participants. Timing of in-hospital coronary artery bypass graft surgery for non-ST-segment elevation myocardial infarction patients results from the National Cardiovascular Data Registry ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines). JACC Cardiovasc Interv. 2010; 3(4): 419–427.

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