Impact of the Presence and Extent of Incomplete Angiographic Revascularization After Percutaneous Coronary Intervention in Acute Coronary Syndromes

Abstract

Background-The clinical significance of incomplete coronary revascularization (ICR) after percutaneous coronary intervention in patients with acute coronary syndromes is unknown. Methods and Results-We performed quantitative angiography of the entire coronary tree in 2954 patients with acute coronary syndromes in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. ICR was variably defined if any lesion with diameter stenosis (DS) cutoffs ranging from Ն30% to Ն70% with reference vessel diameter Ն2.0 mm remained after percutaneous coronary intervention. The primary outcome was 1-year composite rate of major adverse cardiac events (death, myocardial infarction, or ischemia-driven unplanned revascularization). With the use of DS cutoffs Ն30%, Ն40%, Ն50%, Ն60%, and Ն70%, the prevalence of ICR after percutaneous coronary intervention was 75%, 55%, 37%, 25%, and 17%, respectively. The 1-year major adverse cardiac event rate was increased among patients with ICR using all of the DS cutoffs. ICR (Ն50% DS) was associated with higher 1-year rates of myocardial infarction (12.0% versus 8.2%; hazard ratio, 1.50; 95% confidence interval, 1.18 -1.89; Pϭ0.0007) and ischemia-driven unplanned revascularization (15.7% versus 10.2%; hazard ratio, 1.58; 95% confidence interval, 1.28 -1.96; PϽ0.0001), with a trend toward increased mortality (3.1% versus 2.2%; hazard ratio, 1.43; 95% confidence interval, 0.90 -2.27; Pϭ0.13). By multivariable analysis, ICR (Ն50% DS) was an independent predictor of 1-year major adverse cardiac events (hazard ratio, 1.36; 95% confidence interval, 1.12-1.64; Pϭ0.002). The impact of ICR on major adverse cardiac events was similar regardless of chronic total occlusion presence, but it was more pronounced with a greater number of nonrevascularized lesions. Conclusions-Depending on the threshold of percent DS, ICR was present in 17% to 75% of patients with acute coronary syndromes after percutaneous coronary intervention. Regardless of the threshold, ICR was strongly associated with 1-year myocardial infarction, ischemia-driven unplanned revascularization, and major adverse cardiac events. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.

DECISION-CTO: A “negative” clinical trial? Really?

“…I am not truly surprised for the benefit in mortality, because it confirms somehow the data reported in previous observational or post-hoc studies [1][2][3][4][5][6]. I find also clinically unacceptable stating that a treatment is non-inferior to another one, based on a composite endpoint, when its different components move clearly in different directions for each therapeutic option.…”

Effects of Ranolazine on Angina and Quality of Life After Percutaneous Coronary Intervention With Incomplete Revascularization

“…9,10 These events are known to affect QOL and increase healthcare resource consumption, thereby demonstrating the need for additional approaches to improve outcomes in this population. 38,39 Our study included patients with ACS, so in some cases, baseline angina frequency may have been due to a thrombotic process (although we did require chronic angina >30 days prior to admission). Furthermore, there were no differences across arms in SAQ angina frequency over time in patients with or without an initial ACS.…”

Response to Letter Regarding Article, “Impact of the Presence and Extent of Incomplete Angiographic Revascularization After Percutaneous Coronary Intervention in Acute Coronary Syndromes: The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) Trial”

“…We did include extent of atherosclerosis in our original model, and triple-vessel disease was an additional independent correlate of future MACE, although ICR was even more strongly related. 1 Despite our attempts to adjust for measured confounders, observational data are always subject to residual confounding; thus, the observed association between ICR and future MACE we have described does not prove causality.…”

“…With ICR defined using a threshold diameter stenosis Ն50% on quantitative coronary angiography in our original multivariable model, ICR was an independent predictor of 1-year MACE (hazard ratio, 1.36; 95% confidence interval, 1.12-1.64; Pϭ0.002). 1 Although we attempted to adjust for other covariates (including some of those suggested by Sharma et al), not all of these were available or fully represented in this database. For example, baseline left ventricular ejection fraction was present in only 62.8% of patients and was therefore not included in the original model.…”