Impact of incomplete revascularization in patients undergoing PCI for unprotected left main stem stenosis

The Incremental Prognostic Value of the Clinical Residual SYNTAX Score for Patients With Chronic Renal Insufficiency Undergoing Percutaneous Coronary Intervention

Background: The residual SYNTAX score (RSS) is considered a powerful prognostic indicator for determining a reasonable revascularization strategy in patients undergoing percutaneous coronary intervention (PCI), but the absence of clinical parameters is one of the limitations of RSS, especially in the chronic renal insufficiency (CRI) comorbidity setting. The present work aimed to investigate the incremental prognostic value of clinical residual SYNTAX score (CRSS) compared with RSS in CRI cases after PCI.

Methods: Totally 2,468 consecutive CRI cases who underwent PCI from January 2014 to September 2017 were included in this retrospective analysis. CRSS was obtained by multiplying RSS by the modified ACEF score. Individuals with CRSS >0 were considered to have incomplete revascularization and stratified by CRSS tertiles, the remaining cases constituted the complete revascularization (CR) group. The outcomes between these groups were compared.

Results: At a median follow-up of 3 years, compared with CR group, individuals with CRSS >12 showed elevated rates of all clinical outcomes, and those with CRSS ≤ 12 showed similar all-cause and cardiac mortality rates. In multivariable analysis, CRSS was a powerful independent predictive factor of all clinical outcomes. The net reclassification improvement levels of CRSS over RSS for all-cause and cardiac mortality rates were 10.3% (p = 0.007) and 16.4% (p < 0.001), respectively. Compared with RSS, CRSS markedly ameliorated all-cause and cardiac mortality risk stratification.

Conclusions: Compared with RSS, CRSS has incremental predictability for long-term all-cause and cardiac mortality in CRI cases following PCI.

[Comparison of the prognostic value of different clinical, angiographic and scintigraphic scores in stable coronary patients after acute coronary syndrome]

INTRODUCTION

To date, there is no consensus regarding the follow-up of asymptomatic coronary patients with an intermediate risk of events. Indeed, most of cardiovascular events (CVE) occur in asymptomatic patients, hence the clinician's interest in establishing risk stratification scores. In asymptomatic patient, the risk assessment after acute coronary syndrome (ACS) can currently be based on 3 types of score: clinical with, for example, the REACH score; angiographic with the residual SYNTAX score; imaging with different scintigraphic scores. These scores differ widely in terms of evaluation criteria and period of analysis. The aim of our study was therefore, in stable and asymptomatic coronary patients after ACS, to compare these different predictive scores; to establish that the combination of these scores makes it possible to optimize the risk assessment during the follow-up.

METHODS

Our retrospective study included 236 revascularized patients after ACS. Three different risk scores were collected: 1) the residual SYNTAX score, calculated at the time of revascularization; 2) the scintigraphic risk score described by Sharir et al., performed 3 to 12 months after the event and taking into account the extent of ischemia (SDS) and the poststress left ventricular ejection fraction (LVEF). Patients with LVEF <50% and/or moderate to severe ischemic disease (SDS≥2) were considered with an intermediate or high scintigraphic risk; 3) the REACH clinical score calculated on the day of the scintigraphic examination. After the myocardial scintigraphic exam, patients had a 1-year follow-up and CVE were recorded. Continuous data were analyzed either by Student's t-test or non-parametric Mann-Whitney test. The dichotomous data were compared either by the χ² test or by Fisher's exact test.

RESULTS

Forty-eight patients (20.1%) had a CVE during the 1-year follow-up. Thirty patients (13.8%) had a high residual SYNTAX score (≥8) without any correlation observed between the residual SYNTAX score and CVE (P=0.359). 148 patients (57.7%) had a high REACH clinical score (≥11) with no significant correlation observed with CVE (P=0.079). Lastly, 34 patients (14.4%) had an intermediate or high scintigraphic score, this imaging score being strongly correlated with a greater number of CVE (P<0.001). Multivariate analysis revealed 3 independent factors associated with CVE: a scintigraphic score> 2 (OR [(95% CI): 5.530 [2.426-12.605] P<0.001); Peripheral Arterial Obstructive Disease (PAOD) (OR [95% CI]: 8.531 [2.540-28.660] P<0.001); diabetes (OR [95% CI]: 2.86 [1.262-6.517] P=0,012).

CONCLUSION

The combination of the scintigraphic score with two clinical factors, such as PAOD and diabetes, provides optimal prognostic value in the evaluation of asymptomatic and stable patients after ACS. Our study therefore highlights the importance of optimizing evaluation strategies in the follow-up of these patients who remain at risk of post-revascularization CVE.

Impact of the residual SYNTAX score on clinical outcomes after percutaneous coronary intervention for patients with chronic renal insufficiency

OBJECTIVES

This study demonstrated the prognostic value of the residual SYNTAX score (rSS) for patients with chronic renal insufficiency (CRI).

BACKGROUND

The rSS has been proposed as a useful tool for quantifying and stratifying the degree and complexity of residual stenosis and predicting long-term clinical outcomes following percutaneous coronary intervention (PCI). However, it has never been validated for patients with CRI.

METHODS

A total of 2,468 consecutive patients with an estimated glomerular filtration rate <90 ml/min/1.73 m² who underwent PCI were retrospectively enrolled. Patients with rSS >0 were defined as having incomplete revascularization and were stratified into the reasonable incomplete revascularization (RICR; 0 < rSS ≤ 8) group or the incomplete revascularization (ICR; rSS >8) group. Their outcomes were compared to those of the complete revascularization (CR) group.

RESULTS

During follow-up (median, 3 years; range, 1.5-5 years), the ICR group had the highest incidence of all-cause death, cardiac death, myocardial infarction (MI), unplanned revascularization, stroke, and major adverse cardiovascular and cerebrovascular events (MACCE). Despite having higher rates of unplanned revascularization and MACCE, RICR group had comparable all-cause mortality, cardiac mortality, MI, and stroke with CR group. A multivariable Cox analysis indicated that rSS was an independent predictor of cardiac death, MI, unplanned revascularization, stroke, and MACCE. Furthermore, compared with baseline SYNTAX score, rSS had stronger prognostic accuracy when predicting the risk of unplanned revascularization, stroke, and MACCE at the 3-year follow-up.

CONCLUSIONS

The rSS is a powerful indicator of clinical outcomes and may help determine reasonable levels of revascularization for patients with CRI following PCI.

Residual SYNTAX score following coronary artery bypass grafting

Objectives

To quantify residual coronary artery disease measured using the SYNTAX score (SS) and its relation to outcomes after coronary artery bypass grafting (CABG).

Methods

We conducted a retrospective analysis on a consecutive series of 1608 patients [mean age 68 years, standard deviation (SD): 7, F:M, 242:1366] undergoing first-time isolated CABG from 2004 to 2015. The baseline SS was retrospectively determined from preoperative angiograms, and the residual SS (rSS) was measured during assessment of the actual operative report for each patient after CABG. Patients were then stratified according to tercile cut points of low (rSS low 0-11, N  = 537), intermediate (rSS mid  >11-18.5, N  = 539) and high residual SS (rSS high  >18.5, N  = 532). The Cox regression model was used to investigate the impact of rSS on major adverse cardiac and cerebrovascular events (MACCE) at 1 year.

Results

The mean preoperative SS was 26.6 (SD: 9.4) (range 10.1-53), and the residual SS after CABG was 15.3 (SD: 8.4) (range 0-34) ( P  <   0.001 versus preoperative). At 1 year, cumulative incidence of MACCE in the low rSS was 1.5% ( N  = 8/537), 4.5% ( N  = 24/539) in the intermediate and 8.8% ( N  = 47/532) in the high rSS group. Kaplan-Meier analysis showed a statistically significant difference of MACCE-free survival between the three groups (log-rank test, P  <   0.001). The estimated MACCE-free survival rate at 1 year was 98.1% [standard error (SE): 1.6] for the rSS low , 95.5% (SE: 1.9) for the rSS mid , and 90.5% (SE: 1.3) for the rSS high group, respectively. After multivariable adjustment, the rSS high group was independently associated with a higher incidence of MACCE at 1 year (hazard ratio 1.92, 95% confidence interval 1.21-3.23) compared to the rSS low group.

Conclusions

These unanticipated findings suggest that a residual SS may be a useful tool for risk stratification of patients undergoing isolated first-time CABG. Our study may set the stage for further investigations addressing this important clinical question.

Impact of Incomplete Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background

Up to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease (MVD) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization (CR) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta‐analysis.

Methods and Results

A search of PubMed, EMBASE, MEDLINE, Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random‐effects meta‐analysis was used to estimate the odds of adverse outcomes. Meta‐regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty‐eight publications that included 156 240 patients were identified. Odds of death (OR 0.69, 95% CI 0.61‐0.78), repeat revascularization (OR 0.60, 95% CI 0.45‐0.80), myocardial infarction (OR 0.64, 95% CI 0.50‐0.81), and major adverse cardiac events (OR 0.63, 95% CI 0.50‐0.79) were significantly lower in the patients who underwent CR. These outcomes were unchanged on subgroup analysis regardless of the definition of CR. Similar findings were recorded when CR was studied in the chronic total occlusion (CTO) subgroup (OR 0.65, 95% CI 0.53‐0.80). A meta‐regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR.

Conclusion

CR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score‐based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR. These results have important implications for the interventional management of patients with multivessel coronary artery disease.