Revascularization strategies for stable multivessel and unprotected left main coronary artery disease: From BARI to SYNTAX

The coverage of elective revascularisation procedure codes in the National Finnish Hospital Discharge Register

INTRODUCTION

Administrative registers provide an attractive data source for real-life effectiveness studies. The validity of coronary artery disease diagnoses in the Finnish National Hospital Discharge Register (HDR) is high but the validity of revascularization procedure codes (percutaneous coronary intervention; PCI and coronary artery bypass grafting; CABG) are unknown.

METHODS

All elective PCIs (n = 1771) and CABGs (n = 1819), performed at the Heart Center, Kuopio University Hospital, Finland between years 2007 and 2014 were identified from the unit's Special Electronic Medical Records (sEMR). Personal identity codes were used to link these data to the HDR. Sensitivity was estimated as proportion of operations recorded in sEMR and HDR.

RESULTS

With the strictest assumption of exactly the same intervention day in HDR and sEMR, the sensitivity for procedure codes were 84.6% for PCI and 97.1% for CABG, respectively. When a one-day difference was allowed in the dates, the sensitivity increased to 87.6% for PCI and 98.0% for CABG. Altogether 62.1% of elective PCIs and 69.2% of CABGs were correctly classified as elective procedures in the HDR.

CONCLUSION

The potential of the research application of the HDR extends beyond traditionally used diagnostic codes. One feasible application is the assessment of real-life effectiveness of different procedures. KEY MESSAGES The majority of PCIs (87.6%) and CABGs (98.0%), performed in the Heart Center, Kuopio University Hospital responsible for the treatment of approximately one fifth of the Finnish population, were captured by the Finnish National Hospital Discharge Register. However, only 62.1% of elective PCIs and 69.2% of CABGs were correctly classified as elective procedures in the HDR. Electivity data were missing from approximately one third of the procedures. This study produces new information of the potential use of HDR for real-life effectiveness studies to support evidence-based decision making in health care.

The SYNTAX score is correlated with long-term outcomes of coronary artery bypass grafting for complex coronary artery lesions

OBJECTIVES

We analysed retrospectively the long-term outcomes of conventional coronary artery bypass grafting (CABG) as employed routinely for complex coronary lesions by observing patients with low (0-22), intermediate (23-32) and high (≥33) SYNTAX scores. The purpose of this study was to evaluate the correlation between the SYNTAX score and long-term major adverse cardiac and cerebrovascular events (MACCEs) including all-cause death, stroke, myocardial infarction (MI) and repeat revascularization after CABG.

METHODS

The study enrolled 396 consecutive patients with stable and untreated left main and/or three-vessel disease, who had been referred to our heart team from 2000 through 2009. They all routinely underwent conventional CABG. The three groups (low score; n = 159, intermediate score; n = 150, high score; n = 87) were compared, looking at the primary endpoint of MACCE and its components. We also analysed the effects of diverse variables on long-term MACCEs after the operation.

RESULTS

The cumulative 10-year MACCE rates in patients with low, intermediate and high SYNTAX score were 25.3, 35.8 and 48.1%, respectively. The Kaplan-Meier cumulative event curves showed a significantly higher MACCE rate after CABG in patients with a higher SYNTAX score than in those with a lower score (log-rank P = 0.0012). This was mainly because of a significantly increased rate of repeat revascularization in the higher SYNTAX score group (log-rank P = 0.0032). The cumulative rate of repeat revascularization at 10 years in patients having low, intermediate and high SYNTAX score were, respectively, 4.6, 15.7 and 16.8%. The cumulative rates of the combined outcomes of death/stroke/MI at 10 years did not show statistical differences between the three groups (22.3% with low, 25.0% with intermediate and 38.4% with high score, log-rank P = 0.063). In the multivariable analysis, the SYNTAX score [hazard ratio (HR) 1.03, P = 0.0043] and logistic EuroSCORE II (HR 1.34, P = 0.0012) were found to be significant predictors of long-term MACCEs.

CONCLUSIONS

The SYNTAX score is correlated with long-term outcomes, in terms of MACCEs, after conventional CABG for complex coronary lesions and is prognostic of long-term outcomes of CABG for patients with complex lesions.

Long-term outcomes and risk analyses of coronary bypass for left main disease

BACKGROUND

We retrospectively analyzed the long-term outcomes and risk predictors of conventional coronary artery bypass grafting routinely employed for patients with left main disease.

METHODS

From January 2000 through December 2009, conventional coronary artery bypass grafting was routinely employed in 193 consecutive patients with left main disease. Long-term analyses were performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events which included all-cause death, stroke, myocardial infarction, and repeat revascularization. We also analyzed the effects of variables on major adverse cardiac and cerebrovascular events at 9 years after the operation.

RESULTS

The overall 9-year rates of combined outcomes (death, stroke, myocardial infarction), repeat revascularization, and major adverse cardiac and cerebrovascular events were 20.2%, 8.9%, 27.7%, respectively. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes at 9 years (hazard ratio 1.04, p = 0.033), repeat revascularization at 9 years (hazard ratio 1.11, p = 0.0030), and major adverse cardiac and cerebrovascular events at 9 years (hazard ratio 1.07, p = 0.0003).

CONCLUSIONS

With our routine strategy of conventional coronary artery bypass for left main disease, patients revealed excellent long-term outcomes in terms of major adverse cardiac and cerebrovascular events. These results provide a suitable benchmark against which long-term outcomes of percutaneous coronary intervention for left main disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after coronary artery bypass for left main disease.

Long-term outcomes and comparison after conventional coronary artery bypass grafting for left main disease between patients classified as percutaneous coronary intervention recommendation classes II and III

OBJECTIVES

We retrospectively analysed long-term outcomes after conventional coronary artery bypass grafting (CABG) between patients having left main (LM) disease who should have been assigned class II and those assigned class III recommendation for percutaneous coronary intervention (PCI) according to the 2010 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines.

METHODS

From January 2000 to December 2009, conventional CABG was routinely employed in 180 consecutive patients with previously untreated and stable LM lesion. A comparison between two groups (CABG for PCI class II and CABG for PCI class III) was performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, stroke [cerebral vascular accident (CVA)], myocardial infarction (MI) and repeat revascularization. We also analysed the effects of variables on MACCE at 8 years after the operation.

RESULTS

The overall 8-year MACCE rates were significantly lower in the CABG for PCI class II group than in the CABG for PCI class III group (9.7% class II vs 31.1% class III; P = 0.0005). This was largely because of an increased rate of repeat revascularization (1.2% class II vs 13.8% class III; P = 0.0029). The cumulative rate of the combined outcomes of all death/CVA/MI was significantly lower in the CABG for PCI class II group (8.5% class II vs 19.2% class III; P = 0.048); there was no observed difference between the groups for all-cause death, CVA and MI. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes (Death/CVA/MI) at 8 years [odds ratio (OR) 1.05, P = 0.023], repeat revascularization at 8 years (OR 1.11, P = 0.0013) and MACCE at 8 years (OR 1.07, P < 0.0001).

CONCLUSIONS

In our routine strategy of conventional CABG for LM disease, patients believed to be PCI candidates for LM disease have significantly better long-term outcomes as characterized by combined outcomes (Death/CVA/MI), repeat revascularization and MACCE. These results provide a suitable benchmark against which long-term outcomes of PCI for LM disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after CABG for LM disease.

Long-term clinical outcome after percutaneous coronary intervention in grafts vs native vessels in patients with previous coronary artery bypass grafting

BACKGROUND

The long-term clinical outcome of patients with previous coronary artery bypass grafting (CABG), undergoing percutaneous coronary intervention (PCI) is not clear.

METHODS

Observational, retrospective study of post-CABG patients, who underwent PCI in either a graft or a native vessel.

RESULTS

Out of 221 consecutive patients, those with PCI in both native vessel and graft (N=16) and missing follow-up data (N=15) were excluded. Out of the remaining 190 patients (age 67.9±9.6 years; 90.0% men), the graft-PCI group (N=88) had more occluded native vessels (2.1±0.8 vs 1.6±0.8; P<0.001), and fewer totally occluded grafts (0.55±0.6 vs 0.75±0.8; P=0.05) compared with the native vessel-PCI group (N=102). On follow-up (median duration 28 months), the incidence of major adverse cardiac events (MACEs), cardiac death, and repeat revascularization was higher in graft-PCI group compared with native vessel-PCI group (43.2% vs 19.6%, log-rank P<0.001; 19.3% vs 6.9%, log-rank P=0.008; and 23.9% vs 12.7%, log-rank P=0.02, respectively). Graft-PCI was independently associated with higher risk for major adverse cardiac events (hazard ratio [HR], 2.84; 95% confidence interval [CI], 1.45-5.57; P=0.002), cardiac death (HR, 3.44; 95% CI, 1.16-10.22; P=0.03) and repeat revascularization (HR, 2.41; 95% CI, 1.02-5.72; P=0.046).

CONCLUSIONS

Post-CABG patients, undergoing graft compared with native vessel-PCI, have worse long-term clinical outcome. Prospective studies are needed to elucidate the optimal revascularization strategy for such patients.