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Mortality After Repeat Revascularization Following PCI or CABG
Study Questions:
What is the incidence and impact on mortality of repeat revascularization (RR) after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) through a 3-year follow-up period in the EXCEL trial?
Methods:
All patients with LMCAD and site-assessed low or intermediate SYNTAX score randomized to PCI (n = 948) or CABG (n = 957) in the EXCEL trial were included.
Results:
During 3-year follow-up, there were 346 RR procedures (259 [74.9%] were PCI and 87 [25.1%] were CABG) among 185 patients. Median time to the first RR was 347 days (interquartile range [IQR], 182-570) after PCI and 257 days (IQR, 83-628) after CABG.
Randomization to PCI was associated with higher rates of any RR (12.9% vs. 7.6%; hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.28-2.33). Most of this difference emerged beyond 6 months (4.4% vs. 9.9%; HR, 2.33; 95% CI, 1.59-3.41). The cause of RR was stent thrombosis in 8/117 patients (7.1%) after PCI and symptomatic graft occlusion in 42/68 patients (62.7%) after CABG.
Higher body mass index, insulin-treated diabetes mellitus, and need for hemodynamic support during the procedure were associated with a higher risk of RR after PCI, while statin use at discharge was protective (adjusted HR, 0.30; 95% CI, 0.16-0.50; p = 0.0003). Younger age, female sex, and peripheral artery disease were independent predictors of RR after CABG.
Need for RR was independently associated with increased risk of 3-year all-cause mortality (HR, 2.05; 95% CI, 1.13-3.70) and cardiovascular mortality (HR, 4.22; 95% CI, 2.10-8.48) consistently after both PCI and CABG. Of note, the risk of mortality after RR peaked within the first 30 days and then declined over time.
Conclusions:
RR during follow-up was performed less frequently after CABG than PCI and was associated with increased mortality after both procedures.
Perspective:
The effect on mortality following RR was greater early after the event (within 30 days) and then attenuated over time, suggesting that the actual event of RR per se was associated with increased risk. Another key finding is a threefold risk reduction in RR amongst statin-treated patients at discharge, which highlights the importance of lipid-lowering and optimal medical therapy in such patients after both PCI and CABG. Greater mortality after RR by CABG suggests CABG should be reserved for RR in those who are not amenable to repeat PCI, irrespective of the initial revascularization approach. The overall lower rate of RR after CABG compared with PCI makes one wonder if CABG should be preferred over PCI in these patients, but this may also reflect inherent differences in the risks of these two strategies.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine
Keywords: Acute Coronary Syndrome, Body Mass Index, Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Hemodynamics, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Lipids, Myocardial Revascularization, Percutaneous Coronary Intervention, Peripheral Arterial Disease, Risk Reduction Behavior, Stents, Thrombosis
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