Relative benefit of coronary artery bypass grafting versus stent-assisted percutaneous coronary intervention for angina pectoris and multivessel coronary disease in women versus men (one-year results from the Stent or Surgery trial)

Risk of spinal surgery among individuals who have been re-vascularized for coronary artery disease

HYPOTHESIS

Revascularization is a more effective intervention to reduce future postop complications.

METHODS

Patients undergoing elective spine fusion surgery were isolated in the PearlDiver database. Patients were stratified by having previous history of vascular stenting (Stent), coronary artery bypass graft (CABG), and no previous heart procedure (No-HP). Means comparison tests (chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, and comorbidities. Binary logistic regression assessed the odds of 30-day and 90-day postoperative (postop) complications associated with each heart procedure (Odds Ratio [95 % confidence interval]). Statistical significance was set p < 0.05.

RESULTS

731,173 elective spine fusion patients included. Overall, 8,401 pts underwent a CABG, 24,037 pts Stent, and 698,735 had No-HP prior to spine fusion surgery. Compared to Stent and No-HP patients, CABG patients had higher rates of morbid obesity, chronic kidney disease, and diabetes (p < 0.001 for all). Meanwhile, stent patients had higher rates of PVD, hypertension, and hyperlipidemia (all p < 0.001). 30-days post-op, CABG patients had significantly higher complication rates including pneumonia, CVA, MI, sepsis, and death compared to No-HP (all p < 0.001). Stent patients vs. No-HF had higher 30-day post-op complication rates including pneumonia, CVA, MI, sepsis, and death. Furthermore, adjusting for age, comorbidities, and sex Stent was significantly predictive of a MI 30-days post-op (OR: 1.90 [1.53-2.34], P < 0.001). Additionally, controlling for levels fused, stent patients compared to CABG patients had 1.99x greater odds of a MI within 30-days (OR: 1.99 [1.26-3.31], p = 0.005) and 2.02x odds within 90-days postop (OR: 2.2 [1.53-2.71, p < 0.001).

CONCLUSION

With regards to spine surgery, coronary artery bypass graft remains the gold standard for risk reduction. Stenting does not appear to minimize risk of experiencing a post-procedure cardiac event as dramatically as CABG.

Comparison of percutaneous coronary intervention (with drug-eluting stents) versus coronary artery bypass grafting in women with severe narrowing of the left main coronary artery (from the Women-Drug-Eluting stent for LefT main coronary Artery disease Registry)

Women typically present with coronary artery disease later than men with more unfavorable clinical and anatomic characteristics. It is unknown whether differences exist in women undergoing treatment for unprotected left main coronary artery (ULMCA) disease. Our aim was to evaluate long-term clinical outcomes in women treated with percutaneous coronary intervention (PCI) with drug-eluting stents versus coronary artery bypass grafting (CABG). All consecutive women from the Drug-Eluting stent for LefT main coronary Artery disease registry with ULMCA disease were analyzed. A propensity matching was performed to adjust for baseline differences. In total, 817 women were included: 489 (59.8%) underwent treatment with PCI with drug-eluting stents versus 328 (40.2%) with CABG. Propensity score matching identified 175 matched pairs, and at long-term follow-up there were no differences in all-cause (odds ratio [OR] 0.722, 95% confidence interval [CI] 0.357 to 1.461, p=0.365) or cardiovascular (OR 1.100, 95% CI 0.455 to 2.660, p=0.832) mortality, myocardial infarction (MI; OR 0.362, 95% CI 0.094 to 1.388, p=0.138), or cerebrovascular accident (CVA; OR 1.200, 95% CI 0.359 to 4.007, p=0.767) resulting in no difference in the primary study objective of death, MI, or CVA (OR 0.711, 95% CI 0.387 to 1.308, p=0.273). However, there was an advantage of CABG in major adverse cardiovascular and cerebrovascular events (OR 0.429, 95% CI 0.254 to 0.723, p=0.001), driven exclusively by target vessel revascularization (OR 0.185, 95% CI 0.079 to 0.432, p<0.001). In women with significant ULMCA disease, no difference was observed after PCI or CABG in death, MI, and CVA at long-term follow-up.

Trends in coronary artery bypass surgery: impact on early outcomes

BACKGROUND

improvements in nonsurgical revascularization have left a group of higher-risk patients presenting for operation in a later stage of coronary artery disease. We undertook this study to analyze temporal changes in demographic and clinical profiles and outcomes of cardiac surgical patients.

METHODS

we identified and retrieved preoperative, intraoperative, and postoperative variables for 3064 consecutive patients who underwent myocardial revascularization at the Aga Khan University Hospital between 2006 and 2011. Mortality and morbidity outcomes were compared using univariate and multivariate analyses.

RESULTS

mean age, prevalence of left ventricular systolic dysfunction, unstable angina, mean number of occluded vessels, and arrhythmias at presentation increased steadily over time. The prevalence of diabetes, chronic lung disease, peripheral vascular disease, prior stroke, prior myocardial infarction, and left main disease declined. Operative mortality did not change significantly (3.5% vs. 3.8%, p = 0.512). Determinants of operative mortality included older age, female sex, renal insufficiency, left ventricular systolic dysfunction, and longer bypass and crossclamp times.

CONCLUSION

coronary operations are increasingly performed in higher-risk patients with greater comorbidities. Despite this, operative mortality has not increased.

Revascularization Strategies in Women with Stable Cardiovascular Disease: What do the Trials Reveal?

Cardiovascular disease (CAD) is the leading cause of death worldwide in both women and men. Although the prevalence of CAD is less in women, those women affected by CAD die more often than men. Women are underrepresented in cardiovascular studies, making it difficult to determine the outcomes of different revascularization strategies. This review summarizes the current data on gender outcomes for percutaneous coronary intervention and coronary bypass grafting.

Gender gap in acute coronary heart disease: Myth or reality?

AIM

To investigate potential gender differences in the prevalence of cardiovascular risk factors, cardiovascular disease (CVD) management, and prognosis in acute coronary syndrome (ACS).

METHODS

A systematic literature search was performed through Medline using pre-specified keywords. An additional search was performed, focusing specifically on randomized controlled clinical trials in relation to therapeutic intervention and prognosis. In total, 92 relevant articles were found.

RESULTS

Women with CVD tended to have more hypertension and diabetes at the time of presentation, whereas men were more likely to smoke. Coronary angiography and revascularization by percutaneous coronary intervention were performed more often in men. Women were at a greater risk of short-term mortality and complications after revascularization. Interestingly, women under 40 years presenting with ACS were at highest risk of cardiovascular death compared with men of the same age, irrespective of risk factors. This disadvantage disappeared in older age. The long-term mortality risk of ACS was similar in men and women, and even in favor of women.

CONCLUSION

Mortality rates are higher among young women with ACS, but this difference tends to disappear with age, and long-term prognosis is even better among older women.

[Stenting or coronary artery bypass surgery for triple vessel disease?]

This review was undertaken to objectively analyse the cumulated medical literature on techniques of myocardial revascularization (angioplasty, bare metal stenting, drug eluting stenting, coronary artery surgery) in multivessel coronary artery disease. Randomized trials, meta analyses and registries comparing these treatment modalities show a short and long term advantage of surgery over percutaneous techniques for angina recurrence and need for repeat revascularization, although mortality and myocardial infarction rate do not seem statistically different. Diabetes mellitus, chronic renal failure and female gender represent high risk subgroups. Data on drug eluting stents are to date limited to the short term; however, it does not seem that drug eluting stents have resolved the need for repeat revascularization. Stenting addresses focal lesion whereas future revascularization occurs on other coronary sites by progression of coronary disease. Cardiologists should objectively inform the consenting coronary multivessel disease patient on the risk of repeat revascularization inherent to percutaneous techniques and on the weight of actual data favouring surgery in multivessel disease.

Sex-specific effects of diabetes on adverse outcomes after percutaneous coronary intervention: trends over time

BACKGROUND

Diabetes is a stronger risk factor for coronary heart disease in women than in men. Whether diabetes also poses greater risks to women after percutaneous coronary intervention (PCI) has not been examined.

METHODS

We examined 20586 PCI procedures at Emory University Hospitals (Atlanta, GA) between 1990 and 2003. Hazard ratios (HRs) for 1-year major adverse cardiac events were calculated comparing diabetic with nondiabetic patients by sex and study year. Data were adjusted for demographic and clinical factors using Cox proportional hazards models.

RESULTS

Despite increasing patient age and comorbidity burden, diabetic and nondiabetic men had a significant improvement in PCI outcomes between 1990 and 2003 (P < .001). Diabetic women also tended to have improved PCI outcomes over time (P = .073), but not nondiabetic women (P = .206). Overall, diabetes had a stronger association with adverse outcomes in women (HR 1.93, 95% CI 1.55-2.40) than in men (HR 1.26, 95% CI 1.09-1.47) (P = .002 for the interaction between sex and diabetes). The excess risk associated with diabetes in women, however, was largely driven by early study years (1990-1993). This excess risk associated with diabetes in women declined over time, and diabetes had a similar effect on outcomes in both women and men in more recent years (P = .010 for the interaction between sex, diabetes, and time).

CONCLUSIONS

Percutaneous coronary intervention outcomes of diabetic and nondiabetic men have improved in recent years. However, among women, diabetic patients had greater improvements in outcomes after PCI compared with nondiabetic patients. As a result, diabetes is no longer a stronger risk factor for adverse outcomes after PCI in women than in men.

Current trends in coronary artery disease in women

PURPOSE OF REVIEW

There are some striking sex differences regarding presentation, symptoms and sign, diagnosis, and treatment of coronary artery disease. Historically, healthcare delivery to women has been plagued with treatment bias favoring men. This review will present relevant cardiovascular physiologic sex differences, current treatment options for coronary artery disease both surgical and medical, and clinical outcomes of such treatments.

RECENT FINDINGS

In the past, pharmacologic and interventional studies generally excluded women from their subjects. As a result, women have been traditionally treated based on the findings in their male counterparts. Recent studies examining sex differences in the treatment of coronary artery disease have given new insight into the hormonal and behavioral influences associated with coronary artery disease. Finally, these studies have drawn attention to possibly inadvertent discrepancies in the way men and women are treated for coronary artery disease.

SUMMARY

Despite significant advances in medical and surgical approaches to treat coronary artery disease, it remains and will continue to be the most important healthcare challenge of the 21st century. Whereas efforts are underway to encourage inclusion of more women in therapeutic trials, the educational process, particularly in medical school, needs to broadly address sex specific pathophysiology and treatment, rather than relying on sub-subspecialty training for optimizing healthcare delivery in women.

Long term survival and quality of life after myocardial revascularization with respect to age and sex distribution

Introduction. Quality of life assessment and survival analysis are a "gold standard" in assessing treatment quality in general. In the absence of a universally accepted integral index, we developed our own QOLi-NS (Quality of life index - Novi Sad) as a disease specific index. The aim of this study was to investigate long-term survival and quality of life after myicardial revascularization with respect to sex and age. Material and methods. The study included 563 coronary patients operated on at the University Clinic of Cardiovascular Surgery in Sremska Kamenica, in the period from September 1, 1995 to June 1, 1998. The patients were divided into two groups with respect to sex and age; two age categories were defined: younger and older than 65 years of age. Quality of life was evaluated using Integral quality of life index QOLi - NS. Actuarial life table was used to establish the survival curve. Results. After myocardial revascularization, all investigated patients demonstrated a considerable improvement in quality of life with statistically significant differences with respect to age and sex. The highest postoperative quality of life (QOLi-NS), and the best survival rate were found in male patients and in patients younger than 65 years. Conclusion. The gathered data confirmed a significant improvement in quality of life and survival rate after myocardial revascularization in all groups of patients. A statistically significant difference in survival rate was determined with respect to the patients age. Improved quality of life in patients older than 65 years proved that myocardial revascularization is a good therapeutic option for these patients. .

The impact of age on outcomes after coronary artery bypass surgery versus stent-assisted percutaneous coronary intervention: one-year results from the Stent or Surgery (SoS) trial

BACKGROUND

Relative outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) may differ between younger and older patients. There are no data comparing the age-related CABG versus PCI outcomes in the stent era.

METHODS

The SoS trial compared CABG (n = 500) and stent-assisted PCI (n = 488). The impact of treatment assignment on 1-year outcomes was evaluated by age < or = 65 years (n = 295, CABG; n = 298, PCI) and > 65 years (n = 205, CABG; n = 190, PCI).

RESULTS

One-year procedural outcomes were similar between treatment groups regardless of age, with the exception of more repeat revascularizations after PCI (age < or = 65, 16.1% vs 4.8%; age > 65, 19.5% vs 3.4%; both P < .001). Six and 12-month Seattle Angina Questionnaire scores improved from baseline in both age and treatment groups. However, CABG was associated with greater improvement in physical limitation, angina frequency, and quality of life in younger patients at 6 and 12 months (12-month difference in improvement between CABG and PCI: 5.6, 4.8, and 3.9 points for 3 domains), whereas in the elderly a significant benefit of CABG observed at 6 months did not persist at 12 months (12-month difference: 0.9, 1.9, and 1.4). One-year costs were significantly higher after CABG regardless of age.

CONCLUSIONS

Although PCI and CABG result in similar rates in clinical outcomes irrespective of age, younger patients reported more health status benefits from CABG as compared with PCI, whereas in older patients the 2 approaches resulted in similar 1-year health status benefits.

Determinants of health-related quality of life in patients with coronary artery disease

BACKGROUND

Health-related quality of life (HRQL) is increasingly being assessed as an outcome parameter, especially in chronic diseases such as coronary artery disease (CAD), in which the goal of treatment is not only to prolong life but also to relieve symptoms and improve function.

DESIGN

This study was carried out as a non-randomized prospective multicentre study.

METHODS

Patients (N = 432) with CAD were assessed at baseline, 1 and 3 months after treatment assignment [medication, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)]. HRQL was assessed using the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) and the Short Form 36 (SF-36). Depressive and anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale. Routine clinical data including disease severity were collected.

RESULTS

The short and intermediate-term results revealed HRQL differences between PCI and CABG in the month immediately after intervention despite the almost identical reduction in angina severity over the first month in both groups. PCI was associated with a relatively rapid increase in HRQL in the first month, with little further change by 3 months. In contrast, after CABG there was an initial deterioration in HRQL, which then improved significantly. The change in depression and anxiety score uniquely accounted for most of the change in the SF-36 (6%, 64%) and MacNew scales (4%, 69%), whereas treatment accounted for less than 1% in any HRQL scale score changes.

CONCLUSIONS

There appears to be evidence suggesting that HRQL changes after treatments in patients with CAD may be more strongly influenced by mood disturbance than by treatment methods.

Risk factors for impaired health status differ in women and men treated with percutaneous coronary intervention in the drug-eluting stent era

OBJECTIVES

In patients treated with percutaneous coronary intervention (PCI) in the drug-eluting stent era, we compared women's and men's health status 6 and 12 months post-PCI and investigated whether predictors of poor health status at 12 months are similar for women and men.

METHODS

Consecutive patients (n=692; 28% women) treated with PCI completed the 36-item Short-Form Health Survey (SF-36) 6 and 12 months post-PCI.

RESULTS

There was a significant improvement in health status over time (P<.001), but women experienced a significantly poorer health status compared with men (P<.001) at 6 and 12 months, adjusting for differences in baseline characteristics and health status at 6 months. Predictors of impaired health status were generally different for women and men. In women, the predominant predictors were previous coronary artery bypass graft (CABG) surgery, renal impairment, and older age; in contrast, in men, older age was associated with better functioning. In women, previous CABG was associated with a 4-15 fold increased risk of impaired health status. Health status at 6 months was a predictor of all SF-36 domains at 12 months in both women and men.

CONCLUSIONS

Women reported poorer health status compared with men 6 and 12 months post-PCI, and predictors of impaired health status generally differed for women and men. Further studies examining risk factors for adverse outcomes for women and men separately, which will lead to better risk stratification in research and clinical practice, are warranted.

The impact of acute coronary syndrome on clinical, economic, and cardiac-specific health status after coronary artery bypass surgery versus stent-assisted percutaneous coronary intervention: 1-year results from the stent or surgery (SoS) trial

BACKGROUND

Data are limited regarding the impact of acute coronary syndromes (ACSs) on the relative benefits of coronary artery bypass grafting (CABG) versus stent-assisted percutaneous coronary intervention (PCI).

METHODS

The SoS trial compared patients with multivessel disease who were randomly assigned to CABG (n = 500) or stent-assisted PCI (n = 488). The impact of treatment on 1-year outcomes was compared in ACS (n = 126, CABG; n = 116, PCI) and non-ACS (n = 374, CABG; n = 372, PCI) subgroups.

RESULTS

Baseline characteristics were similar between treatment groups within ACS and non-ACS groups, as was the 1-year composite incidence of mortality and myocardial infarction (ACS, 5.2% for PCI vs 5.6% for CABG, P = .89; non-ACS, 7.0% vs 8.3%, P = .50). The need for repeat revascularizations was higher after PCI versus CABG within each subgroup (ACS, 15.5% vs 7.1%, P = .04; non-ACS, 18.0% vs 3.2%, P < .001). At 6 and 12 months, scores on the Seattle Angina Questionnaire improved significantly in patients with and without ACS. In patients without ACS, CABG was associated with greater improvement in physical limitation, angina frequency, and quality of life at 6 and 12 months. In patients with ACS, there was only a nonsignificant slight trend toward greater improvement with CABG at 1 year. The total 1-year costs for PCI and CABG in patients without ACS were 5760 pound sterling and 8509 pound sterling (Delta = 2749 pound sterling, 95% CI 1890 pound sterling - 3409 pound sterling), and in patients with ACS, 8014 pound sterling and 10080 pound sterling (Delta = 2066 pound sterling, 95% CI -690 pound sterling to 3487 pound sterling).

CONCLUSIONS

In patients with and without ACS, CABG had similar clinical outcomes, less need for repeat revascularization and higher costs compared to PCI. The benefit of CABG relative to PCI in improving patients' health status tended to be greater in patients without ACS than in patients with ACS.

Percutaneous transluminal coronary angioplasty with stents versus coronary artery bypass grafting for people with stable angina or acute coronary syndromes

BACKGROUND

Coronary artery bypass graft surgery (CABG) replaces obstructed vessels with ones from other parts of the body. Alternatively, obstructions are remodelled using catheter-based techniques such as percutaneous coronary angioplasty with the use of stents. Though less invasive, stenting techniques are limited by the re-narrowing of treated vessels (restenosis). We examined evidence on cardiac-related outcomes occurring after CABG or stenting, with implications for resource use, resource allocation and informing patient choice.

OBJECTIVES

To examine evidence from randomised controlled trials (RCTs) on benefit of stents or CABG in reducing cardiac events in people with stable angina or acute coronary syndrome (ACS).

SEARCH STRATEGY

CENTRAL (Issue 2 2004), EMBASE (1990 to 2004), MEDLINE (1990 to 2004) and handsearching to July 2004.

SELECTION CRITERIA

Only RCTs comparing stents used with PTCA with CABG were included. Participants were adults with stable angina or ACS and unstable angina and had either single or multiple vessel disease. Published and unpublished sources were considered.

DATA COLLECTION AND ANALYSIS

Outcomes included composite event rate (major adverse cardiac event, event free survival), death, acute myocardial infarction (AMI), repeat revascularisation and binary restenosis as well as information on design and baseline characteristics. Quality assessment was completed independently. Meta-analyses are presented as odds ratios, 95% confidence intervals (CI) using a fixed-effect model. Heterogeneity between trials was assessed.

MAIN RESULTS

Nine studies (3519 patients) were included. Four RCTs included patients with multiple vessel disease, five focused on single vessel disease. Four studies reported beyond 1 year. No statistical differences were observed between CABG and stenting for meta-analysis of mortality or AMI, but there was heterogeneity. Composite cardiac event and revascularisation rates were lower for CABG than for stents. Odds ratios resulting from meta-analysis of event rate data at 1 year were, odds ratio 0.43 (95% CI 0.35 to 0.54) and at 3 years, odds ratio 0.37 (95% CI 0.29 to 0.48). Odds ratios for revascularisation at 1 year were, odds ratio 0.18 (95% CI 0.13 to 0.25) and at 3 years, odds ratio 0.09 (95% CI 0.02 to 0.34). Binary restenosis at 6 months (single vessel trials) favoured CABG, odds ratio 0.29 (95% CI 0.17 to 0.51).

AUTHORS' CONCLUSIONS

CABG is associated with reduced rates of major adverse cardiac events, mostly driven by reduced repeat revascularisation. However, the RCT data are limited by follow-up, unrepresentative samples and rapid development of both surgical techniques and stenting. Research on real-world patient population or patient level data meta-analyses may identify risk factors and groupings who may benefit most from one strategy over the other.