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Contemporary PCI in Patients With Three-Vessel Disease
Quick Takes
- Contemporary “state-of-the-art PCI” includes liberal use of coronary physiology, intravascular ultrasound, thin-strut biodegradable polymer drug-eluting stents, enhanced treatments of chronic total occlusions, and optimized medical therapy.
- When comparing outcomes among patients undergoing PCI in the original SYNTAX I cohort (2005-2007), patients who underwent “state-of-the-art PCI” (2014-2015) in the current SYNTAX II study had lower rates of repeat revascularization, MI, and mortality at 5 years.
- A prespecified analysis of the SYNTAX II study cohort and SYNTAX I CABG cohort showed similar outcomes at 5 years.
Study Questions:
Does “state-of-the-art percutaneous coronary intervention (PCI),” which integrates use of SYNTAX score II, coronary physiology, thin-strut biodegradable polymer drug-eluting stents, intravascular ultrasound, enhanced treatments of chronic total occlusion, and optimized medical therapy improve outcomes in patients with de novo three-vessel disease?
Methods:
SYNTAX II was a multicenter, single-arm, open-label study of patients requiring revascularization who demonstrated clinical equipoise for treatment with either coronary artery bypass grafting (CABG) or PCI, predicted by the SYNTAX score II. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), which included any revascularization. The comparators were a matched PCI cohort trial and a matched CABG cohort, both from the SYNTAX I trial.
Results:
A total of 454 patients were enrolled and 443 completed 5-year follow-up. At 5 years, the MACCE rate in SYNTAX II was significantly lower than in the SYNTAX I PCI cohort (21.5% vs. 36.4%, p < 0.001). This reflected lower rates of revascularization (13.8% vs. 23.8%, p < 0.001) and myocardial infarction (MI) (2.7% vs. 10.4%, p < 0.001), consisting of both procedural MI (0.2% vs. 3.8%, p < 0.001) and spontaneous MI (2.3% vs. 6.9%, p = 0.004). All-cause mortality was lower in SYNTAX II (8.1% vs. 13.8%, p = 0.013), reflecting a lower rate of cardiac death (2.8% vs. 8.4%, p < 0.001). MACCE outcomes at 5 years among patients in SYNTAX II and predefined patients in the SYNTAX I CABG cohort were similar (21.5% vs. 24.6%, p = 0.35).
Conclusions:
Use of the SYNTAX II PCI strategy in patients with de novo three-vessel disease led to improved and durable clinical results when compared to predefined patients treated with PCI in the original SYNTAX I trial. A predefined exploratory analysis found no significant difference in MACCE between SYNTAX II PCI and matched SYNTAX I CABG patients at 5-year follow-up.
Perspective:
This nonrandomized multicenter analysis highlights the developments and evolution in coronary intervention over a decade. When comparing outcomes among patients undergoing PCI in the original SYNTAX I cohort (2005-2007), patients who underwent “state-of-the-art PCI” (liberal use of coronary physiology, intravascular ultrasound, thin-strut biodegradable polymer drug-eluting stents, enhanced treatments of chronic total occlusions, and optimized medical therapy) in the current SYNTAX II study had lower rates of repeat revascularization, MI, and mortality at 5 years. In fact, a prespecified analysis of the current cohort and SYNTAX I CABG cohort showed similar outcomes at 5 years. Findings support the need for a randomized trial of select patients with multivessel coronary artery disease comparing outcomes after “state-of-the-art” PCI and CABG.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and Coronary Artery Disease, Interventions and Imaging, Echocardiography/Ultrasound
Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Coronary Occlusion, Physiology, Drug-Eluting Stents, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Polymers, Ultrasonography, Ultrasonography, Interventional, Vascular Diseases
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