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Assessing the association of appropriateness of coronary revascularization and 1-year clinical outcomes for patients with stable coronary artery disease in China.

ABSTRACT: BACKGROUND:The Chinese appropriate use criteria (AUC) for coronary revascularization was released in 2016 to improve the use of coronary revascularization. This study aimed to evaluate the association between the appropriateness of coronary revascularization based on the Chinese AUC and 1-year outcomes in stable coronary artery disease (CAD) patients. METHODS:We conducted a prospective, multi-center cohort study of stable CAD patients with coronary lesion stenosis ?50%. After the classification of appropriateness based on Chinese AUC, patients were categorized into the coronary revascularization group or the medical therapy group based on treatment received. The primary outcome was a composite of death, myocardial infarction, stroke, repeated revascularization, and ischemic symptoms with hospital admission. RESULTS:From August 2016 to August 2017, 6085 patients were consecutively enrolled. Coronary revascularization was associated with a lower adjusted hazard of 1-year major adverse cardiovascular and cerebrovascular events (MACCEs; hazard ratio [HR]: 0.62; 95% confidence interval [CI]: 0.45-0.86; P?=?0.004) than medical therapy in patients with appropriate indications (n?=?1617). No significant benefit in 1-year MACCEs was found after revascularization compared to after medical therapy in patients with uncertain indications (n?=?2658, HR: 0.81; 95% CI: 0.52-1.25; P?=?0.338) and inappropriate indications (n?=?1810, HR: 0.80; 95% CI: 0.51-1.23; P?=?0.308). CONCLUSIONS:In patients with appropriate indications according to Chinese AUC, coronary revascularization was associated with significantly lower risk of MACCEs at 1 year. No benefit was found in coronary revascularization in patients with inappropriate indications. Our findings provide evidence for using Chinese AUC to guide clinical decision-making. CLINICAL TRIAL REGISTRATION:NCT02880605. https://www.clinicaltrials.gov.

SUBMITTER: Lin S

PROVIDER: S-EPMC7028197 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Assessing the association of appropriateness of coronary revascularization and 1-year clinical outcomes for patients with stable coronary artery disease in China.

Lin Shen S Zhang Heng H Rao Chen-Fei CF Chen Si-Peng SP Qiao Shu-Bin SB Yan Hong-Bing HB Dou Ke-Fei KF Wu Yong-Jian YJ Tang Yi-Da YD Yang Xin-Chun XC Shen Zhu-Jun ZJ Liu Jian J Zheng Zhe Z

Chinese medical journal 20200101 1

<h4>Background</h4>The Chinese appropriate use criteria (AUC) for coronary revascularization was released in 2016 to improve the use of coronary revascularization. This study aimed to evaluate the association between the appropriateness of coronary revascularization based on the Chinese AUC and 1-year outcomes in stable coronary artery disease (CAD) patients.<h4>Methods</h4>We conducted a prospective, multi-center cohort study of stable CAD patients with coronary lesion stenosis ≥50%. After the ...[more]

PMID: 31923098

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Project description:AimsCoronary flow reserve (CFR) is an integrated measure of the entire coronary vasculature, and is a powerful prognostic marker in coronary artery disease (CAD). The extent to which coronary revascularization can improve CFR is unclear. This study aimed to evaluate the impact of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) on CFR in patients with stable CAD.Methods and resultsIn a prospective, multicentre observational study, CFR was measured by 15O-water positron emission tomography as the ratio of stress to rest myocardial blood flow at baseline and 6 months after optimal medical therapy (OMT) alone, PCI, or CABG. Changes in the SYNTAX and Leaman scores were angiographically evaluated as indicators of completeness of revascularization. Follow-up was completed by 75 (25 OMT alone, 28 PCI, and 22 CABG) out of 82 patients. The median SYNTAX and Leaman scores, and baseline CFR were 14.5 [interquartile range (IQR): 8-24.5], 5.5 (IQR: 2.5-12.5), and 1.94 (IQR: 1.67-2.66), respectively. Baseline CFR was negatively correlated with the SYNTAX (ρ = -0.40, P < 0.001) and Leaman scores (ρ = -0.33, P = 0.004). Overall, only CABG was associated with a significant increase in CFR [1.67 (IQR: 1.14-1.96) vs. 1.98 (IQR: 1.60-2.39), P < 0.001]. Among patients with CFR <2.0 (n = 41), CFR significantly increased in the PCI [1.70 (IQR: 1.42-1.79) vs. 2.21 (IQR: 1.78-2.49), P = 0.002, P < 0.001 for interaction between time and CFR] and CABG groups [1.28 (IQR: 1.13-1.80) vs. 1.86 (IQR: 1.57-2.22), P < 0.001]. The reduction in SYNTAX or Leaman scores after PCI or CABG was independently associated with the percent increase in CFR after adjusting for baseline characteristics (P = 0.012 and P = 0.011, respectively).ConclusionCoronary revascularization ameliorated reduced CFR in patients with obstructive CAD. The degree of improvement in angiographic CAD burden by revascularization was correlated with magnitude of improvement in CFR.

Project description:AimOptimal revascularization strategy in multivessel (MV) coronary artery disease (CAD) eligible for percutaneous management (PCI) and surgery remains unresolved. We evaluated, in a randomized clinical trial, residual myocardial ischemia (RI) and clinical outcomes of MV-CAD revascularization using coronary artery bypass grafting (CABG), hybrid coronary revascularization (HCR), or MV-PCI.MethodsConsecutive MV-CAD patients (n = 155) were randomized (1 : 1 : 1) to conventional CABG (LIMA-LAD plus venous grafts) or HCR (MIDCAB LIMA-LAD followed by PCI for remaining vessels) or MV-PCI (everolimus-eluting CoCr stents) under Heart Team agreement on equal technical and clinical feasibility of each strategy. SPECT at 12 months (primary endpoint of RI that the trial was powered for; a measure of revascularization midterm efficacy and an independent predictor of long-term prognosis) preceded routine angiographic control.ResultsData are given, respectively, for the CABG, HCR, and MV-PCI arms. Incomplete revascularization rate was 8.0% vs. 7.7% vs. 5.7% (p=0.71). Hospital stay was 13.8 vs. 13.5 vs. 4.5 days (p < 0.001), and sick-leave duration was 23 vs. 16 vs. 8 weeks (p < 0.001). At 12 months, RI was 5 (2, 9)% vs. 5 (3, 7)% vs. 6 (3, 10)% (median; Q1, Q3) with noninferiority p values of 0.0006 (HCR vs. CABG) and 0.016 (MV-PCI vs. CABG). Rates of angiographic graft stenosis/occlusion or in-segment restenosis were 20.4% vs. 8.2% vs. 5.9% (p=0.05). Clinical target vessel/graft failure occurred in 12.0% vs. 11.5% vs. 11.3% (p=0.62). Major adverse cardiac and cerebral event (MACCE) rate was similar (12% vs. 13.4% vs. 13.2%; p=0.83).ConclusionIn this first randomized controlled study comparing CABG, HCR, and MV-PCI, residual myocardial ischemia and MACCE were similar at 12 months. There was no midterm indication of any added value of HCR. Hospital stay and sick-leave duration were shortest with MV-PCI. While longer-term follow-up is warranted, these findings may impact patient and physician choices and healthcare resources utilization. This trial is registered with NCT01699048.

Project description:BackgroundImprecise interpretation of coronary angiograms was reported and resulted in inappropriate revascularization. Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score is a comprehensive system to evaluate the complexity of the overall lesions. We hypothesized that a real-time SYNTAX score feedback from image analysts may rectify the mis-estimation and improve revascularization appropriateness in patients with stable coronary artery disease (CAD).MethodsIn this single-center, historical control study, patients with stable CAD with coronary lesion stenosis ≥50% were consecutively recruited. During the control period, SYNTAX scores were calculated by treating cardiologists. During the intervention period, SYNTAX scores were calculated by image analysts immediately after coronary angiography and were provided to cardiologists in real-time to aid decision-making. The primary outcome was revascularization deemed inappropriate by Chinese appropriate use criteria for coronary revascularization.ResultsA total of 3245 patients were enrolled and assigned to the control group (08/2016-03/2017, n = 1525) or the intervention group (03/2017-09/2017, n = 1720). For SYNTAX score tertiles, 17.9% patients were overestimated and 4.3% were underestimated by cardiologists in the control group. After adjustment, inappropriate revascularization significantly decreased in the intervention group compared with the control group (adjusted odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.73-0.95; P = 0.007). Both inappropriate percutaneous coronary intervention (adjusted OR: 0.82; 95% CI: 0.74-0.92; P < 0.001) and percutaneous coronary intervention utilization (adjusted OR: 0.88; 95% CI: 0.79-0.98; P = 0.016) decreased significantly in the intervention group. There was no significant difference in 1-year adverse cardiac events between the control group and the intervention group.ConclusionsReal-time SYNTAX score feedback significantly reduced inappropriate coronary revascularization in stable patients with CAD.Clinical trial registrationNos. NCT03068858 and NCT02880605; https://www.clinicaltrials.gov.

Project description:BACKGROUND:The relation between diabetes mellitus, glycemic control, and ischemic and bleeding events is poorly described in outpatients with stable coronary artery disease receiving modern secondary prevention. METHODS AND RESULTS:The multicenter CORONOR (Suivi d'une cohorte de patients Coronariens stables en région Nord-pas-de-Calais) registry enrolled 4184 outpatients with stable coronary artery disease, including 1297 patients (31%) with diabetes mellitus. A recent glycosylated hemoglobin (HbA1c) was available for 1146 diabetic patients, and 48% had HbA1c ?7%. We analyzed 5-year ischemic (cardiovascular death, myocardial infarction, and stroke) and bleeding (Bleeding Academic Research Consortium ?3) outcomes, according to diabetic status and glycemic control. When compared with nondiabetic patients, the ischemic risk was higher in diabetic patients with HbA1c ?7% (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.25-1.93) but not in diabetic patients with HbA1c <7% (HR, 1.06; 95% CI, 0.83-1.36). Diabetic patients with HbA1c ?7% were at higher risk than diabetic patients with HbA1c <7% (HR, 1.47; 95% CI, 1.09-1.98). When compared with nondiabetic patients, the bleeding risk was higher in diabetic patients, with HbA1c <7% (HR, 1.66; 95% CI, 1.04-2.67) and in those with HbA1c ?7% (HR, 1.75; 95% CI, 1.07-2.86). No difference in bleeding risk was observed between diabetic patients with HbA1c ?7% versus those with HbA1c <7%. Similar results were obtained when adjusted for baseline characteristics. CONCLUSIONS:The 5-year increased risk of ischemic events in patients with stable coronary artery disease with diabetes mellitus was restricted to those with HbA1c ?7%. By contrast, the increase in bleeding risk associated with diabetes mellitus was observed in patients with HbA1c ?7% and in patients with HbA1c <7%. The level of HbA1c should be taken into account for future research and may help physicians to manage prolonged antithrombotic therapies in this high-risk subgroup.

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Assessing the association of appropriateness of coronary revascularization and 1-year clinical outcomes for patients with stable coronary artery disease in China.

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Assessing the association of appropriateness of coronary revascularization and 1-year clinical outcomes for patients with stable coronary artery disease in China.

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