Long-Term Outcomes of Complete Versus Incomplete Revascularization for Patients with Multivessel Coronary Artery Disease and Left Ventricular Systolic Dysfunction in Drug-Eluting Stent Era

Abstract

We aimed to investigate that complete revascularization (CR) would be associated with a decreased mortality in patients with multivessel disease (MVD) and reduced left ventricular ejection fraction (LVEF). We enrolled a total of 263 patients with MVD and LVEF <50% who had undergone percutaneous coronary intervention with drug-eluting stent between March 2003 and December 2010. We compared major adverse cardiac and cerebrovascular accident (MACCE) including all-cause death, myocardial infarction, any revascularization, and cerebrovascular accident between CR and incomplete revascularization (IR). CR was achieved in 150 patients. During median follow-up of 40 months, MACCE occurred in 52 (34.7%) patients in the CR group versus 51 (45.1%) patients in the IR group (P=0.06). After a Cox regression model with inverse-probability-of-treatment-weighting using propensity score, the incidence of MACCE of the CR group were lower than those of the IR group (34.7% vs. 45.1%; adjusted hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.44-0.95, P=0.03). The rate of all-cause death was significantly lower in patients with CR than in those with IR (adjusted HR, 0.48; 95% CI, 0.29-0.80, P<0.01). In conclusion, the achievement of CR with drug-eluting stent reduces long-term MACCE in patients with MVD and reduced LVEF.Graphical Abstract

Differential Clinical Outcomes Between Angiographic Complete Versus Incomplete Coronary Revascularization, According to the Presence of Chronic Kidney Disease in the Drug‐Eluting Stent Era

“…In addition, the better outcomes seen in the angiographic CR group were similarly observed in various subgroups, especially in patients with younger age (<65 years), acute coronary syndrome, and left ventricular dysfunction. These results are also in line with previous studies that evaluated the prognostic implication of angiographic CR in patients with acute ST‐segment elevation MI or left ventricular dysfunction 23, 24, 25…”

To complete, or not to complete, that is the question of revascularization in percutaneous coronary intervention with drug-eluting stents for multivessel disease

“…In 3 (11,13,16) of the 5 studies, C-RV was associated with reduced R-RV. In 8 (6,9-11,13-16) of the 11 studies, C-RV was associated with reduced MAC(C)E. There were a number of important issues, however, in the aforementioned studies (1,(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) of C-RV versus IC-RV in DES-PCI for MV-CAD (except for AMI) (Figure 1). First, "angiographic" (successful angioplasty of all diseased lesions in the major epicardial coronary vessels and their first degree side branches) and "proximal" C-RV definitions (successful angioplasty of all diseased proximal arteries) according to a study by Kim et al (18) are more accurate and clinically relevant.…”

“…In one (1) of the 3 studies, C-RV was associated with reduced MI. Only two studies (1,6) reported no association of C-RV with stroke. In 3 (11,13,16) of the 5 studies, C-RV was associated with reduced R-RV.…”

“…The design of all studies was a non-randomized observational study, and all but one (13) studies reported adjusted HRs for outcomes of interest in "C-RV vs. IC-RV" or "IC-RV vs. C-RV". Nine (1,5-7,9,11,13-15), 5 (6,8,9,16,17), 3 (1,6,11), 2 (1,6), 5 (1,6,11,13,16), and 11 studies (1,6,(8)(9)(10)(11)(12)(13)(14)(15)(16) provided HRs for all-cause death, cardiac death, MI, stroke, R-RV, and MAC(C)E, respectively. In 5 (5-7,14,15) of the 9 studies, C-RV was associated with reduced all-cause death.…”

“…Our systematic search using keywords including "complete" or "completeness"; "incomplete" or "culprit"; "revascularization"; and "drug-eluting" identified 14 studies (1,(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) summarized in Tables 1,2. The design of all studies was a non-randomized observational study, and all but one (13) studies reported adjusted HRs for outcomes of interest in "C-RV vs. IC-RV" or "IC-RV vs. C-RV".…”