Quantification and Impact of Untreated Coronary Artery Disease After Percutaneous Coronary Intervention

Abstract

Objectives The purpose of this study was to quantify the extent and complexity of residual coronary stenoses following percutaneous coronary intervention (PCI) and to evaluate its impact on adverse ischemic outcomes. Background Incomplete revascularization (IR) after PCI is common, and most studies have suggested that IR is associated with a worse prognosis compared with complete revascularization (CR). However, formal quantification of the extent and complexity of residual atherosclerosis after PCI has not been performed. Methods The baseline Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score (bSS) from 2,686 angiograms from patients with moderate- and high-risk acute coronary syndrome (ACS) undergoing PCI enrolled in the prospective ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial was determined. The SS after PCI was also assessed, generating the “residual” SS (rSS). Patients with rSS >0 were defined as having IR and were stratified by rSS tertiles, and their outcomes were compared to the CR group. Results The bSS was 12.8 ± 6.7, and after PCI the rSS was 5.6 ± 2.2. Following PCI, 1,084 patients (40.4%) had rSS = 0 (CR), 523 (19.5%) had rSS >0 but ≤2, 578 (21.5%) had rSS >2 but ≤8, and 501 patients (18.7%) had rSS >8. Age, insulin-treated diabetes, hypertension, smoking, elevated biomarkers or ST-segment deviation, and lower ejection fraction were more frequent in patients with IR compared with CR. The 30-day and 1-year rates of ischemic events were significantly higher in the IR group compared with the CR group, especially those with high rSS. By multivariable analysis, rSS was a strong independent predictor of all ischemic outcomes at 1 year, including all-cause mortality (hazard ratio: 1.05, 95% confidence interval: 1.02 to 1.09, p = 0.006). Conclusions The rSS is useful to quantify and risk-stratify the degree and complexity of residual stenosis after PCI. Specifically, rSS >8.0 after PCI in patients with moderate- and high-risk ACS is associated with a poor 30-day and 1-year prognosis.

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

“…However, other studies reported unclear benefit of angiographic CR over IR 15, 16, 17. Along with the constant refinement of revascularization techniques and devices, especially DES, which showed improved clinical outcomes over bare‐metal stents,18 later studies indicated that angiographic CR with DES implantation showed better clinical outcomes than IR 19, 20, 21. However, even in the second‐generation DES era, with enhanced safety and efficacy, high‐risk patients, such as those with diabetes mellitus or CKD, have shown significantly worse clinical outcomes than patients without high‐risk comorbidities 1, 22.…”

Impact of Coronary Artery Revascularization Completeness on Outcomes of Patients With Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement

“…Comparing outcomes of patients undergoing TAVR according to their anatomic extent of disease, quantified by the rSS, the best validated tool for assessment of revascularization completeness. 16,17 2. Comparing outcomes of patients with CAD undergoing TAVR stratified according to prespecified rSS threshold and comparing outcomes of patients with CAD above/below an rSS threshold to outcomes of patients without CAD undergoing TAVR.…”

Invasive or non-invasive imaging for detecting high-risk coronary lesions?

“…However, the small number of the reported events and the fact that this analysis did not take into account the angiographic variables associated with clinical outcomes (i.e. the Syntax score, or the residual Syntax score) did not allow us to draw safe conclusions about the additive prognostic value of CTCA in this population [149][150][151][152].…”