Poll Results: Is Complete Revascularization Important for Optimal PCI Outcomes?
- Complete revascularization produced better clinical outcomes at 4 years compared with incomplete revascularization, although the differences were attenuated after adjustment for baseline covariates.
- In patients with angina managed invasively, safely attaining complete revascularization optimized quality of life compared to conservative management, with the greatest benefit occurring in patients with more angina. No benefit was identified relative to the extent of stress-induced ischemia.
- Regarding the importance of the complete revascularization definition, improved clinical outcomes were best defined by functional as opposed to anatomic findings. Conversely, quality-of-life benefits were best defined by anatomic in contrast to functional complete revascularization.
Details of ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) have been summarized in multiple reports. In brief, with ongoing follow-up, the results to 4 years show time-dependent but similar overall outcomes for optimal medical therapy (an early advantage driven by greater peri-procedure adverse events) in the invasive arm. Later follow-up shows more new ischemic events in the optimal medical therapy-only group. Patients with the greatest angina tend to have greater benefit for revascularization.
At the American College of Cardiology 2021 Annual Scientific Session, a retrospective analysis from the Angiographic Core Lab in New York assessed the results based on the extent to which completeness of revascularization was achieved. The results were analyzed based on complete revascularization identified by either anatomic or functional definitions. Interestingly, the results were dependent on the definition. Overall, 43.6% of patients treated in the invasive arm achieved complete revascularization by the anatomic definition, and 58.5% achieved complete revascularization by the functional definition. After analysis to create statistically comparative populations, there was a suggested advantage for complete revascularization, best defined by the anatomic definition. Conversely, complete revascularization defined by functional criteria was a better predictor of complete revascularization benefits in quality-of-life outcomes.
Thanks and congratulations to the poll respondents. This was a bit tricky, but you were on it. Overall, the poll affirmed the belief that complete revascularization has a benefit regarding clinical outcomes as well as quality-of-life outcome endpoints. Furthermore, the specific measure of complete revascularization, anatomic versus functional, appears to be variable based on the endpoint being tested. Importantly, Dr. Stone emphasized that one must weigh the anatomic complexity and risk of achieving complete revascularization compared to any potential benefit to minimize risk while optimizing outcome.
Keywords: Quality of Life, Retrospective Studies, Conservative Treatment, Follow-Up Studies, Angina Pectoris, Ischemia, Longitudinal Studies, Surveys and Questionnaires, Coronary Artery Disease
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