Impact of routine angiographic follow-up after percutaneous coronary intervention with drug-eluting stents in the SPIRIT III randomized trial at three years

Tooth Loss is a Risk Factor for Cardiovascular Disease Mortality: A Systematic Review with Meta-analyses

INTRODUCTION

The current evidence linking tooth loss and cardiovascular disease mortality is inconclusive. Thus, the aim of this systematic review was to explore the association between tooth loss and cardiovascular disease (CVD) mortality.

METHODS

A comprehensive literature search of databases and gray literature included: Web of Science, Scopus, PubMed, Cochrane Central Register of Controlled Trials, Google Scholar, various digital repositories. The included studies reported on CVD mortality and tooth loss. The Newcastle-Ottawa scale was used to assess the quality of included studies. Random-effects meta-analysis method, sub-group analysis (based on the tooth loss categories (edentulous and fewer than 10 teeth present), meta-regression (based on the number. of confounders), publication bias, and sensitivity analysis were performed.

RESULTS

Twelve articles met the eligibility criteria with an overall "Good" quality. A significant association between tooth loss (edentulous or less than 10 teeth present) and CVD mortality was found in the primary meta-analysis, which compiled data from 12 studies. The estimated hazard ratio was 1.66 (95% CI: 1.32-2.09), and there was high heterogeneity (I2 = 82.42). Subgroup analysis revealed that the edentulous subgroup showed a higher risk with no significant heterogeneity, while the subgroup with fewer than 10 teeth showed a higher risk with substantial heterogeneity. Meta-regression analysis did not reveal any significant impact (P = .626) on whether variations in the number of confounders across studies would substantially affect the overall findings. No publication bias was detected and the sensitivity analysis based on the critical confounders also confirmed that tooth loss as a risk factor for CVD mortality (hazard ratio = 1.52, 95% CI: 1.28-1.80), (I2 51.82%).

CONCLUSION

The present systematic review reported that being edentulous or having lesser than 10 teeth is a predictive indicator of CVD mortality.

Cost-effectiveness of follow-up invasive coronary angiography after percutaneous coronary stenting: a real-world observational cohort study in Japan

OBJECTIVES

Follow-up invasive coronary angiography (FUICA) after percutaneous coronary intervention (PCI) has been shown to increase the rate of early coronary revascularisation without reducing the incidence of subsequent myocardial infarction or death. However, no studies have evaluated the cost-effectiveness of FUICA in patients after coronary stenting. Therefore, this study aimed to evaluate the cost-effectiveness of FUICA after PCI.

DESIGN

Retrospective observational cohort study.

SETTING

497 hospitals.

PARTICIPANTS AND INTERVENTIONS

Overall, 558 patients who underwent coronary artery stenting between April 2014 and March 2015 were matched and included in the invasive angiographic follow-up (AF) group (n=279), in which patients underwent FUICA 6-12 months after PCI, or in the clinical follow-up alone group (CF; n=279) using propensity scores.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was the composite outcome of death, myocardial infarction, urgent coronary revascularisation, stroke or hospitalisation for the heart failure. The secondary endpoints included all-cause death, non-fatal myocardial infarction, urgent revascularisation, coronary artery bypass grafting, stroke, hospitalisation for the heart failure and any coronary revascularisation after a minimum of 6 months of follow-up.

RESULTS

Costs were calculated as direct medical expenses based on medical fee billing information. The cumulative 3-year incidence of the primary endpoint was 5.3% in the AF group and 4.7% in the CF group (HR 1.02; 95% CI 0.47 to 2.20; p=0.98). The total incremental cost at the 3-year endpoint in the AF group was US$1874 higher than that in the CF group (US$8947±US$5684 vs US$7073±US$6360; p≤0.001).

CONCLUSIONS

FUICA increased the costs but did not improve clinical benefits. Thus, FUICA is not economically more attractive than CF alone.

TRIAL REGISTRATION NUMBER

UMIN000039768.

Hospital-level variation in follow-up strategies after percutaneous coronary intervention, revealed in health claims data of Korea

This study sought to determine hospital variation in the use of follow-up stress testing (FUST) and invasive coronary angiography (FUCAG) after percutaneous coronary intervention (PCI). The claims records of 150,580 Korean patients who received PCI in 128 hospitals between 2008 and 2015 were analyzed. Patient were considered to have undergone FUST and FUCAG, when these testings were performed within two years after discharge from the index hospitalization. Hierarchical generalized linear and frailty models were used to evaluate binary and time-to-event outcomes. Hospital-level risk-standardized FUCAG and FUST rates were highly variable across the hospitals (median, 0.41; interquartile range [IQR], 0.27-0.59; median, 0.22; IQR, 0.08-0.39, respectively). The performances of various models predicting the likelihood of FUCAG and FUST were compared, and the best performance was observed with the models adjusted for patient case mix and individual hospital effects as random effects (receiver operating characteristic curves, 0.72 for FUCAG; 0.82 for FUST). The intraclass correlation coefficients of the models (0.41 and 0.68, respectively) indicated that a considerable proportion of the observed variation was related to individual institutional effects. Higher hospital-level FUCAG and FUST rates were not preventive of death or myocardial infarction. Increased repeat revascularizations were observed in hospitals with higher FUCAG rates.

Follow-up tests and outcomes for patients undergoing percutaneous coronary intervention: analysis of a Japanese administrative database

Follow-up tests after percutaneous coronary intervention (PCI) are considered inappropriate for asymptomatic patients. Despite this perception, many cardiologists conduct follow-up tests as routine practice. The objective of this study was to investigate the survival benefits of follow-up testing after PCI in a real-world setting in Japan. A nationwide Japanese administrative database was used to identify unselected patients who underwent PCI with stent implantation between January 2010 and December 2013. We used time-dependent Cox proportional hazards models to evaluate the association between follow-up testing and outcomes. The primary outcome was the composite of all-cause death and acute myocardial infarction (AMI). Among a total of 21,409 patients, 15,095 (70.5%) completed follow-up testing, of whom 9814 (45.0%) underwent coronary angiography. During a median of 2.7 years of observation, the primary outcome occurred less frequently for patients who underwent follow-up testing (1.21 vs. 4.51% per year; adjusted hazard ratio, 0.59; 95% CI 0.52-0.67; p < 0.001). Individual rates of all-cause death and AMI were also lower for the patients who underwent follow-up testing. Follow-up testing was associated with a lower risk of all-cause death and/or AMI. However, because of the unexpectedly large effect and many limitations of the administrative data, our findings should be further investigated to assess the net benefit of follow-up tests. In addition, we do not intend to encourage routine follow-up tests for patients without clear clinical indications. Follow-up tests should be conducted in accordance with clinical indications.

Routine angiographic follow-up versus clinical follow-up in patients with diabetes following percutaneous coronary intervention with drug-eluting stents in Korean population

AIMS

The usefulness of routine angiographic follow-up (RAF) and clinical follow-up (CF) after percutaneous coronary intervention (PCI) in patients with diabetes is not well understood. We compare 3-year clinical outcomes of RAF and CF in diabetic patients underwent PCI with drug-eluting stents (DES).

METHODS

A total of 843 patients with diabetes who underwent PCI with DES were enrolled. RAF was performed at 6-9 months after PCI (n = 426). Rest of patients were medically managed and clinically followed (n = 417); symptom-driven events were captured. After propensity score matched analysis, 2 propensity-matched groups (262 pairs, n = 524, C-statistic = 0.750) were generated. The primary endpoint was major adverse cardiac events (MACE), the composite of total death, non-fatal myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), non-target vessel revascularization (Non-TVR).

RESULTS

During the 3-year follow-up period, the cumulative incidence of target lesion revascularization [TLR: hazard ratio (HR), 4.07; 95% confidence interval (CI), 1.18-9.34; p = 0.001], target vessel revascularization (TVR: HR, 4.02; 95% CI, 1.93-8.40; p < 0.001), non-TVR (HR, 4.92; 95% CI, 1.68-14.4; p = 0.004) and major adverse cardiac events (MACE: HR, 2.53; 95% CI, 1.60-4.01, p < 0.001) were significantly higher in the RAF group. However, the incidence of total death, non-fatal MI were similar between the two groups.

CONCLUSIONS

RAF following index PCI with DES in patients with diabetes was associated with increased incidence of revascularization and MACE without changes of death or re-infarction rates and increased TLR and TVR rates in both first- and second-generation DES.

Routine Angiographic Follow-Up After Coronary Artery Disease Revascularization: Is Seeing Believing?

PURPOSE OF THE REVIEW

Coronary artery disease is a major cause of mortality and morbidity in the world, and PCI and CABG account for over a million procedures performed annually in the USA. The goal of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is to achieve complete revascularization (CR) if at all possible. However, restenosis and stent thrombosis (ST) remain the Achilles heel of contemporary PCI with restenosis rates between 10 and 30% with bare metal stents to 5-15% after drug-eluting stents and ST rates of around 0.8 vs 1.2%, respectively. Routine angiography after revascularization seems theoretically attractive as this may allow intervention before clinical events occur. In this manuscript, we review the literature regarding routine angiography after PCI or CABG and its outcomes.

RECENT FINDINGS

According to the 2016 update from the American Heart Association (AHA), 15.5 million people above the age of 20 have coronary heart disease (CHD) in the USA. The prevalence of CHD is now almost similar in both men and women, and one American suffers from a myocardial infarction (MI) every 42 s. Recent data from randomized clinical trials and observational studies does not support the use of routine coronary angiography after revascularization in asymptomatic patients. There are some studies which show that routine angiography may have a role in left main or complex coronary interventions; however, these findings are exploratory and were not seen in randomized trials. After reviewing the data on routine angiography after coronary revascularization, we came to the conclusion that current data does not support the use of routine angiography for asymptomatic patients. However, there is a lack of randomized controlled trial in this field with only one recent trial reporting negative outcomes.

Routine angiographic follow-up versus clinical follow-up in patients with multivessel coronary artery diseases following percutaneous coronary intervention with drug-eluting stents: a nested case-control study within a Korean population

OBJECTIVE

The difference in the usefulness of routine angiographic follow-up (RAF) and clinical follow-up (CF) after a percutaneous coronary intervention (PCI) in multivessel coronary artery disease (MVD) patients has not been well clarified as yet.

PATIENTS AND METHODS

A total of 642 consecutive MVD patients who underwent PCI with drug-eluting stents (DES) were enrolled. RAF was performed at 6-9 months after the index PCI (n=374) and others were medically managed and clinically followed (n=268). Patients who experienced clinical events including death, myocardial infarction (MI), and ischemia-driven PCI before 1 year were excluded. To adjust for any potential confounders, a propensity scorematched analysis was carried out using the logistic regression model and two propensity-matched groups (193 pairs, n=386, C-statistic=0.744) were generated. Cumulative clinical outcomes up to 3 years were compared between the RAF group and the CF group.

RESULTS

During the 3-year follow-up period, the cumulative incidence of revascularization [target lesion revascularization: odds ratio (OR), 4.21; 95% confidence interval (CI), 1.67-10.6; P=0.001) and target vessel revascularization (TVR: OR, 4.69; 95% CI, 2.00-11.0; P<0.001, target vessel revascularization: OR, 4.69; 95% CI, 2.00-1011.0; P<0.001] and major adverse cardiovascular events (composite of death, repeat PCI and MI: OR, 2.96; 95% CI, 1.62-105.42, P<0.001) were significantly higher in the RAF group compared with the CF group. However, the 3-year incidence of death (OR, 1.41; 95% CI, 0.44-104.53; P=0.558) or MI (OR, 2.58; 95% CI, 0.79-108.37; P=0.102) was not different between the two groups. In MVD patients treated with second-generation DESs, the incidence of repeat revascularization (target lesion revascularization and target vessel revascularization) was not different between the two groups.

CONCLUSION

Conclusion RAF following index PCI with DES in multivessel CAD patients was associated with increased incidence of revascularization and major adverse cardiovascular events. However, in MVD patients treated with second-generation DESs, repeat revascularization incidence was similar between two different follow-up strategies up to 3 years.

Role of Routine Follow-up Coronary Angiography After Percutaneous Coronary Intervention - Systematic Review and Meta-Analysis

BACKGROUND

Prior studies have shown that routine follow-up coronary angiography (CAG) following percutaneous coronary intervention (PCI) increases the incidence of revascularization without a clear reduction in major adverse clinical events. However, none of these prior studies were adequately powered to evaluate hard clinical endpoints such as myocardial infarction (MI) or death and thus the clinical utility of such practice remains to be determined.Methods and Results:We conducted a systematic review and meta-analysis of randomized trials that compared clinical outcomes after PCI between patients who underwent routine follow-up CAG and those who only had clinical follow-up. Five randomized trials, totaling 4,584 patients met our inclusion criteria, including studies that used sub-randomization and ones that assigned consecutive patients per study protocol. Our results showed that routine follow-up CAG was associated with a lower rate of MI (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.46-0.91; P=0.01) without reduction in all-cause mortality (OR 0.87; 95% CI 0.59-1.28; P=0.48), and a higher rate of target lesion revascularization (OR 1.73; 95% CI 1.42-2.11; P<0.001).

CONCLUSIONS

Our meta-analysis demonstrated that routine follow-up CAG after PCI was associated with a higher rate of revascularization, but also with a reduction in the rate of subsequent MI. Further studies investigating the potential role of routine follow-up angiography may be warranted.

Routine Angiographic Follow-Up versus Clinical Follow-Up after Percutaneous Coronary Intervention in Acute Myocardial Infarction

PURPOSE

Differences in the utility of routine angiographic follow-up (RAF) and clinical follow-up (CF) after percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) are not well understood. The present study aimed to compare the 3-year clinical outcomes of RAF and CF in AMI patients who underwent PCI with drug-eluting stents (DES).

MATERIALS AND METHODS

A total of 774 consecutive AMI patients who underwent PCI with DES were enrolled. RAF was performed at 6 to 9 months after index PCI (n=425). The remaining patients were medically managed and clinically followed (n=349); symptom-driven events were captured. To adjust for any potential confounders, a propensity score matched analysis was performed using a logistic regression model, and two propensity-matched groups (248 pairs, n=496, C-statistic=0.739) were generated. Cumulative clinical outcomes up to 3 years were compared between RAF and CF groups.

RESULTS

During the 3-year follow-up period, the cumulative incidences of revascularization [target lesion revascularization: hazard ratio (HR), 2.40; 95% confidence interval (CI), 1.18-4.85; p=0.015, target vessel revascularization (TVR): HR, 3.33; 95% CI, 1.69-6.58; p=0.001, non-TVR: HR, 5.64; 95% CI, 1.90-16.6; p=0.002] and major adverse cardiac events (MACE; HR, 3.32; 95% CI, 1.92-5.73; p<0.001) were significantly higher in the RAF group than the CF group. However, the 3-year incidences of death and myocardial infarction were not different between the two groups.

CONCLUSION

RAF following index PCI with DES in AMI patients was associated with increased incidences of revascularization and MACE. Therefore, CF seems warranted for asymptomatic patients after PCI for AMI.

The ReACT Trial: Randomized Evaluation of Routine Follow-up Coronary Angiography After Percutaneous Coronary Intervention Trial

OBJECTIVES

The purpose of this study was to evaluate long-term clinical impact of routine follow-up coronary angiography (FUCAG) after percutaneous coronary intervention (PCI) in daily clinical practice in Japan.

BACKGROUND

The long-term clinical impact of routine FUCAG after PCI in real-world clinical practice has not been evaluated adequately.

METHODS

In this prospective, multicenter, open-label, randomized trial, patients who underwent successful PCI were randomly assigned to routine angiographic follow-up (AF) group, in which patients were to receive FUCAG at 8 to 12 months after PCI, or clinical follow-up alone (CF) group. The primary endpoint was defined as a composite of death, myocardial infarction, stroke, emergency hospitalization for acute coronary syndrome, or hospitalization for heart failure over a minimum of 1.5 years follow-up.

RESULTS

Between May 2010 and July 2014, 700 patients were enrolled in the trial among 22 participating centers and were randomly assigned to the AF group (n = 349) or the CF group (n = 351). During a median of 4.6 years of follow-up (interquartile range [IQR]: 3.1 to 5.2 years), the cumulative 5-year incidence of the primary endpoint was 22.4% in the AF group and 24.7% in the CF group (hazard ratio: 0.94; 95% confidence interval: 0.67 to 1.31; p = 0.70). Any coronary revascularization within the first year was more frequently performed in AF group than in CF group (12.8% vs. 3.8%; log-rank p < 0.001), although the difference between the 2 groups attenuated over time with a similar cumulative 5-year incidence (19.6% vs. 18.1%; log-rank p = 0.92).

CONCLUSIONS

No clinical benefits were observed for routine FUCAG after PCI and early coronary revascularization rates were increased within routine FUCAG strategy in the current trial. (Randomized Evaluation of Routine Follow-up Coronary Angiography After Percutaneous Coronary Intervention Trial [ReACT]; NCT01123291).

The role of angiographic follow-up after percutaneous coronary intervention

In the early days of coronary angioplasty, follow-up coronary angiography was often performed to assess restenosis. Angiographic restenosis has been shown to be associated with worse clinical outcomes, though the exact causality has yet to be determined. Numerous studies have repeatedly demonstrated that routine follow-up coronary angiography increases the incidence of target lesion revascularization without a clear reduction in mortality or myocardial infarction. Despite the lack of proven benefit of angiographic follow-up, routine follow-up coronary angiography is still being performed in certain countries and facilities. There are several factors that might explain the lack of benefit of angiographic follow-up: 1) lower incidence of stent failure in the current drug-eluting stent era has attenuated the net clinical benefit of follow-up angiography. 2) Angiographic restenosis might not lead to myocardial ischemia. 3) Patients that do have functionally significant restenosis are often referred for coronary angiography due to clinical indications such as intractable angina. 4) Absence of restenosis at the time of follow-up angiography does not exclude future restenosis. The absence of proven benefit in unselected populations does not necessarily preclude the presence of benefit in selected population, and there may be a subgroup of patients who can benefit from angiographic follow-up such as those with a large myocardial ischemic territory or those at very high risk of restenosis. Until there is more clinical evidence with respect to follow-up angiography, the decision of whether or not to perform it routinely in selected high-risk population should entail an in-depth discussion with the patient.

A multidirectional approach to risk assessment in patients with three-vessel coronary artery disease undergoing percutaneous intervention

BACKGROUND

The SYNTAX score (SS) and Clinical SYNTAX score (CSS) have demonstrated utility as risk-stratifying tools following percutaneous coronary intervention (PCI). However, useful determinants for predicting hard clinical events (HCE: death, nonfatal myocardial infarction, and stroke) in the setting of routinely-performed-angiographic follow-up have yet to be elucidated.

METHODS AND RESULTS

We retrospectively examined the clinical outcomes of 252 three-vessel disease (TVD) patients following PCI. The incidence of HCE at 3 years significantly differed according to CSS (High, 20.2%; Intermediate, 1.2%; and Low, 6.0%; log-rank p<0.001), but not according to SS (High, 14.0%; Intermediate, 5.8%; and Low, 7.3%; log-rank p=0.13). The incidence of repetitive revascularization at 3 years did not differ significantly both among SS (High, 45.2%; Intermediate, 36.5%; and Low, 38.2%; log-rank p=0.22) and CSS (High, 36.9%; Intermediate, 41.7%; and Low, 41.7%; log-rank p=0.88,).

CONCLUSION

Prediction of HCE in patients with TVD following PCI was more accurate with CSS than with SS.

Long-term clinical outcomes of everolimus-eluting stent versus paclitaxel-eluting stent in patients undergoing percutaneous coronary interventions: a meta-analysis

BACKGROUND

Everolimus -eluting stent (EES) is common used in patients undergoing percutaneous coronary interventions (PCI). Our purpose is to evaluate long-term clinical outcomes of everolimus -eluting stent (EES) versus paclitaxel-eluting stent (PES) in patients undergoing percutaneous coronaryinterventions (PCI) in randomized controlled trials (RCTs).

METHODS

We searched Medline, EMBASE, Cochrane Library, CNKI, VIP and relevant websites ( https://scholar-google-com.ezproxy.lib.usf.edu/ ) for articles to compare outcomes between everolimus-eluting stent and paclitaxel-eluting stent without language or date restriction. RCTs that compared the use of everolimus -eluting stent and paclitaxel-eluting stent in PCI were included. Variables relating to patient, study characteristics, and clinical endpoints were extracted. Meta-analysis was performed using RevMan 5.2 software.

RESULTS

We identified 6 published studies (from three randomized trials) more on everolimus-eluting stent (n = 3352) than paclitaxel-eluting (n = 1639), with follow-up duration ranging from 3, 4 and 5 years. Three-year outcomes of everolimus-eluting stent compared to paclitaxel-eluting were as following: the everolimus-eluting stent significantly reduced all-cause death (relative risk [RR]:0.63; 95% confidence interval [CI]: 0.46. to 0.82), MACE (RR: 0.56; 95% CI: 0.41 to 0.77), MI (RR: 0.64; 95% CI: 0.48 to 0.86), TLR (RR: 0.72; 95% CI: 0.59 to 0.88), ID-TLR (RR: 0.74; 95% CI: 0.59 to 0.92) and ST (RR: 0.54; 95% CI: 0.32 to 0.90). There was no difference in TVR between the everolimus-eluting and paclitaxel-eluting (RR: 0.76; 95% CI: 0.58 to 1.10); Four-year outcomes of everolimus-eluting compared to paclitaxel-eluting: the everolimus-eluting significantly reduced MACE (RR: 0.44; 95% CI: 0.18 to 0.98) and ID-TLR (RR: 0.47; 95 % CI: 0.23 to 0.97). There was no difference in MI (RR: 0.48; 95% CI: 0.16 to 1.46), TLR (RR: 0.46; 95% CI: 0.20 to 1.04) and ST ((RR: 0.34; 95% CI: 0.05 to 2.39). Five-year outcomes of everolimus-eluting stent compared to paclitaxel-eluting: There was no difference in ID-TLR (RR: 0.67; 95% CI: 0.45 to 1.02) and ST (RR: 0.71; 95% CI: 0.28 to 1.80).

CONCLUSIONS

In the present meta-analysis, everolimus-eluting appeared to be safe and clinically effective in patients undergoing PCI in comparison to PES in 3-year clinical outcomes; there was similar no difference in reduction of ST between EES and PES in long-term(≥ 4 years) clinical follow-ups. Everolimus-eluting is more safety than paclitaxel-eluting in long-term clinical follow-ups, whether these effects can be applied to different patient subgroups warrants further investigation.

Clinical impact of routine follow-up coronary angiography after second- or third-generation drug-eluting stent insertion in clinically stable patients

BACKGROUND/AIMS

In the bare-metal stent era, routine follow-up coronary angiography (RFU CAG) was used to ensure stent patency. With the advent of drug-eluting stents (DESs) with better safety and efficacy profiles, RFU CAG has been performed less often. There are few data on the clinical impact of RFU CAG after second- or third-generation DES implantation in clinically stable patients with coronary artery disease; the aim of this study was to examine this issue.

METHODS

We analyzed clinical outcomes retrospectively of 259 patients who were event-free at 12-month after stent implantation and did not undergo RFU CAG (clinical follow-up group) and 364 patients who were event-free prior to RFU CAG (angiographic follow-up group). Baseline characteristics were compared between the groups.

RESULTS

The Kaplan-Meier estimated total survival and major adverse cardiac event (MACE)-free survival did not differ between the groups (p = 0.100 and p = 0.461, respectively). The cumulative MACE rate was also not different between the groups (hazard ratio, 0.85; 95% confidence interval, 0.35 to 2.02). In the angiographic follow-up group, 8.8% revascularization was seen at RFU CAG.

CONCLUSIONS

RFU CAG did not affect long-term clinical outcome after second- or third-generation DES implantation in clinically stable patients.

Prognostic role of restenosis in 10 004 patients undergoing routine control angiography after coronary stenting

AIM

Routine control angiography is a valuable tool with high-sensitivity in detecting restenosis after coronary stenting. However, the prognostic role of restenosis is still controversial. We investigated the impact of restenosis on 4-year mortality in patients undergoing routine control angiography after coronary stenting.

METHODS AND RESULTS

All the patients undergoing successful implantation of coronary stents for de novo lesions from 1998 to 2009 and routine control angiography after 6-8 months at two centres in Munich, Germany were studied. Restenosis was defined as diameter stenosis ≥50% in the in-segment area at follow-up angiography. The primary outcome was 4-year mortality. The study included 10 004 patients with 15 004 treated lesions. Restenosis was detected in 2643 (26.4%) patients. Overall, there were 702 deaths during the follow-up. Of these, 218 deaths occurred among patients with restenosis and 484 deaths occurred among patients without restenosis [unadjusted hazard ratio: HR: 1.19; (95% confidence interval CI: 1.02-1.40); P = 0.03]. The Cox proportional hazards model adjusting for other variables identified restenosis as an independent correlate of 4-year mortality [HR: 1.23; (95% CI: 1.03-1.46); P = 0.02]. Other independent correlates of 4-year mortality were age [for each 10-year increase, HR: 2.34; (95% CI: 2.12-2.60); P < 0.001], diabetes mellitus [HR: 1.68; (95% CI: 1.41-1.99); P < 0.001], current smoking habit [HR: 1.39; (95% CI: 1.09-1.76); P = 0.01], and left ventricular ejection fraction [for each 5% decrease, HR: 1.39; (95% CI: 1.31-1.48); P < 0.001].

CONCLUSIONS

In this large cohort of patients, the presence of restenosis at follow-up angiography after coronary stenting was predictive of 4-year mortality. Whether routine control angiography after coronary stenting is beneficial and influences outcomes should be evaluated by properly designed randomized trials.

Impact of scheduled angiographic follow-up in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

Routine scheduled angiographic follow-up (SAF) after percutaneous coronary intervention (PCI) has been associated with a higher rate of target vessel revascularization (TVR). Its benefits are not known. SAF at 13 months after ST-segment elevation myocardial infarction (STEMI) was planned in the first 1,800 successfully stented patients enrolled in the Harmonizing Outcomes with RevascularIZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial. We compared the outcomes of patients with and without SAF at 1 year (before SAF) and at 3 years (after SAF). There were 1,197 patients (66.5% of expected) with and 2,207 patients without SAF. Prior to SAF, the 1-year composite rate of death or myocardial infarction (MI) was not significantly different between the 2 groups (2.7% vs. 3.9%, respectively, P=0.06), although the rate of death was lower (0.1% vs. 2.2%, P<0.0001), nor were there differences in the 1-year rates of TVR, stent thrombosis or major adverse cardiac and cerebral events). At 3 years, death or MI rates were again similar between the groups (8.3% vs. 9.5%, P=0.22), but TVR was more common in the SAF group (17.0% vs. 8.6%, P<0.0001), due to an increase in TVR at time of SAF. In the SAF group, patients in whom TVR was performed before or after the 13-month SAF window had markedly higher 3-year rates of MI and stent thrombosis than patients in whom TVR was performed during SAF or not at all. In conclusion, SAF after primary PCI in STEMI is associated with doubling of the rate of revascularization without an improvement in death or MI, and therefore cannot be recommended.