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Lee G, Malik A, Vervoort D, Tam DY, Marquis-Gravel G, Redfors B, Gaudino M, Fremes SE. Revascularisation in Left Ventricular Systolic Dysfunction: A Meta-analysis of Kaplan-Meier Reconstructed Individual Patient Data. Can J Cardiol 2024:S0828-282X(24)00414-8. [PMID: 38823634 DOI: 10.1016/j.cjca.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Coronary artery disease is a common cause of ischemic left ventricular systolic dysfunction (LVSD), for which the optimal revascularisation strategy remains unclear. We aimed to determine whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) results in greater survival advantage in patients with LVSD. METHODS Study-level (SLMA) and reconstructed individual patient data (rIPDMA) meta-analyses from Kaplan-Meier (KM) survival curves were performed. A systematic search of Medline, Embase, and Cochrane Library was conducted for observational and randomised studies published after 2010 that compared PCI and CABG in patients with left ventricular ejection fraction ≤ 40%. The primary outcome was all-cause mortality at longest follow-up. The secondary outcomes were myocardial infarction (MI), stroke, repeated revascularisation, cardiovascular mortality, and major adverse cardiovascular and cerebrovascular events (MACCE) at longest follow-up. RESULTS Fourteen studies (11 observational, 3 randomised, 13,063 patients) were eligible for the SLMA. Seven contained digitisable KM curves from which individual patient data could be reconstructed. Study-level analysis found PCI to be associated with increased all-cause mortality (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.18-1.69), MI (HR 2.10, 95% CI 1.62-2.72), repeated revascularisation (HR 2.39, 95% CI 1.37-4.17), and MACCE (HR 1.58, 95% CI 1.23-2.03), without significant differences in stroke (HR 0.86, 95% CI 0.39-1.92) or cardiovascular mortality (HR 1.42, 95% CI 0.78-2.59). In the rIPDMA, PCI resulted in increased all-cause mortality (HR 1.57, 95% CI 1.34-1.87) and repeated revascularisation (HR 3.63, 95% CI 3.12-4.21) but overall lower risk of stroke (HR 0.62, 95% CI 0.39-0.99) owing to fewer events during initial follow-up. CONCLUSIONS In patients with ischemic LVSD, PCI was associated with higher risk of all-cause mortality and repeated revascularisation than CABG, but lower risk of short-term stroke. (PROSPERO: CRD42021291408).
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Affiliation(s)
- Grace Lee
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Malik
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Stephen E Fremes
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Tirziu D, Kołodziejczak M, Grubman D, Carrión CI, Driskell LD, Ahmad Y, Petrie MC, Omerovic E, Redfors B, Fremes S, Browndyke JN, Lansky AJ. Impact and Implications of Neurocognitive Dysfunction in the Management of Ischemic Heart Failure. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101198. [PMID: 39131066 PMCID: PMC11308118 DOI: 10.1016/j.jscai.2023.101198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/21/2023] [Accepted: 09/26/2023] [Indexed: 08/13/2024]
Abstract
Neurocognitive dysfunction is common in heart failure (HF), with 30% to 80% of patients experiencing some degree of deficits in one or more cognitive domains, including memory, attention, learning ability, executive function, and psychomotor speed. Although the mechanism is not fully understood, reduced cardiac output, comorbidities, chronic cerebral hypoperfusion, and cardioembolic brain injury leading to cerebral hypoxia and brain damage seem to trigger the neurocognitive dysfunction in HF. Cognitive impairment is independently associated with worse outcomes including mortality, rehospitalization, and reduced quality of life. Patients with poorer cognitive function are at an increased risk of severe disease as they tend to have greater difficulty complying with treatment requirements. Coronary revascularization in patients with ischemic HF has the potential to improve cardiovascular outcomes but risks worsening neurocognitive dysfunction even further. Revascularization by coronary artery bypass grafting carries inherent risks for delirium, cognitive impairment, neurologic injury, and stroke, which are known to exacerbate the risk of neurocognitive dysfunction. Alternatively, percutaneous coronary intervention, as a less-invasive approach, has the potential to minimize the risk of cognitive impairment but has not yet been evaluated as an alternative to coronary artery bypass grafting in patients with ischemic HF. Therefore, it is paramount to raise awareness of the neurocognitive consequences in ischemic HF and devise strategies for recognition and prevention as an important target of patient management and personalized decision making that contributes to patient outcomes.
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Affiliation(s)
- Daniela Tirziu
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Michalina Kołodziejczak
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
- Department of Anesthesiology and Intensive Care, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, Antoni Jurasz University Hospital No.1, Bydgoszcz, Poland
| | - Daniel Grubman
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Carmen I. Carrión
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Lucas D. Driskell
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Yousif Ahmad
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Mark C. Petrie
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Jeffrey N. Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences, Duke University Medical Center, Durham, North Carolina
- Department of Surgery, Division of Cardiovascular & Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
- Center for Cognitive Neuroscience, Duke University Medical Center, Durham, North Carolina
| | - Alexandra J. Lansky
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
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3
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Fremes SE, Marquis-Gravel G, Gaudino MFL, Jolicoeur EM, Bédard S, Masterson Creber R, Ruel M, Vervoort D, Wijeysundera HC, Farkouh ME, Rouleau JL. STICH3C: Rationale and Study Protocol. Circ Cardiovasc Interv 2023; 16:e012527. [PMID: 37582169 DOI: 10.1161/circinterventions.122.012527] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 07/03/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is the recommended mode of revascularization in patients with ischemic left ventricular dysfunction (iLVSD) and multivessel disease. However, contemporary percutaneous coronary intervention (PCI) outcomes have improved with the integration of novel technologies and refinement of revascularization strategies, and PCI is often used in clinical practice in this population. There is a lack of evidence from randomized trials comparing contemporary state-of-the-art PCI versus CABG for the treatment of iLVSD and multivessel disease. This was the impetus for the STICH3C trial (Canadian CABG or PCI in Patients With Ischemic Cardiomyopathy), described here. METHODS The STICH3C trial is a prospective, unblinded, international, multicenter trial with an expected sample size of 754 participants from ≈45 centers. Patients with multivessel/left main coronary artery disease and iLVSD with left ventricular ejection fraction ≤40% considered by the local Heart Team appropriate for and amenable to revascularization by both modes of revascularization will be randomized in a 1:1 ratio to state-of-the-art PCI or CABG. RESULTS The primary end point is the composite of death from any cause, stroke, spontaneous myocardial infarction, urgent repeat revascularization, or heart failure readmission, summarized as a time-to-event outcome. The key hierarchical end point is time to death and frequency of hospitalizations for heart failure. The key safety outcome is a composite of major adverse events. Disease-specific quality-of-life and health economics measures will be compared between groups. Participants will be followed for a median of 5 years, with a minimum follow-up of 4 years. CONCLUSIONS STICH3C will directly inform patients, clinicians, and international practice guidelines about the efficacy and safety of CABG versus PCI in patients with iLVSD. The results will provide novel and broad evidence, including clinical events, health status, and economic assessments, to guide care for patients with iLVSD and severe coronary artery disease. REGISTRATION URL: https://clinicaltrials.gov/; Unique identifier: NCT05427370.
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Affiliation(s)
- Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | | | - Mario F L Gaudino
- Department of Cardiothoracic Surgery (M.F.L.G.), Weill Cornell Medicine, New York City, NY
| | - E Marc Jolicoeur
- Department of Cardiothoracic Surgery (M.F.L.G.), Weill Cornell Medicine, New York City, NY
| | - Sylvain Bédard
- Centre d'excellence sur le partenariat avec les patients et le public, Montreal, Quebec, Canada (S.B.)
| | | | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (M.R.)
| | - Dominique Vervoort
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | - Harindra C Wijeysundera
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | - Michael E Farkouh
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Ontario, Canada (M.E.F.)
| | - Jean-Lucien Rouleau
- Montreal Heart Institute, University of Montreal, Quebec, Canada (G.M.-G., E.M.J., J.-L.R.)
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Daoulah A, Naser MJ, Hersi AS, Alshehri M, Garni TA, Abuelatta R, Yousif N, Almahmeed W, Alasmari A, Aljohar A, Alzahrani B, Abumelha BK, Ghani MA, Amin H, Hashmani S, Hiremath N, Kazim HM, Refaat W, Selim E, Jamjoom A, El-Sayed O, Al-Faifi SM, Feteih MN, Dahdouh Z, Aithal J, Ibrahim AM, Elganady A, Qutub MA, Alama MN, Abohasan A, Hassan T, Balghith M, Hussien AF, Abdulhabeeb IAM, Ahmad O, Ramadan M, Alqahtani AH, Alshahrani SS, Qenawi W, Shawky A, Ghonim AA, Elmahrouk A, Alhamid S, Maghrabi M, Haddara MM, Iskandar M, Shawky AM, Hurley WT, Elmahrouk Y, Ahmed WA, Lotfi A. Impact of left ventricular ejection fraction on outcomes after left main revascularization: g-LM Registry. J Cardiovasc Med (Hagerstown) 2023; 24:23-35. [PMID: 36219153 DOI: 10.2459/jcm.0000000000001383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIMS The impact of left ventricular dysfunction on clinical outcomes following revascularization is not well established in patients with unprotected left main coronary artery disease (ULMCA). In this study, we evaluated the impact of left ventricular ejection fraction (LVEF) on clinical outcomes of patients with ULMCA requiring revascularization with percutaneous coronary intervention (PCI) compared with coronary artery bypass graft (CABG). METHODS The details of the design, methods, end points, and relevant definitions are outlined in the Gulf Left Main Registry: a retrospective, observational study conducted between January 2015 and December 2019 across 14 centres in 3 Gulf countries. In this study, the data on patients with ULMCA who underwent revascularization through PCI or CABG were stratified by LVEF into three main subgroups; low (l-LVEF <40%), mid-range (m-LVEF 40-49%), and preserved (p-LVEF ≥50%). Primary outcomes were hospital major adverse cardiovascular and cerebrovascular events (MACCE) and mortality and follow-up MACCE and mortality. RESULTS A total of 2137 patients were included; 1221 underwent PCI and 916 had CABG. During hospitalization, MACCE was significantly higher in patients with l-LVEF [(10.10%), P = 0.005] and m-LVEF [(10.80%), P = 0.009], whereas total mortality was higher in patients with m-LVEF [(7.40%), P = 0.009] and p-LVEF [(7.10%), P = 0.045] who underwent CABG. There was no mortality difference between groups in patients with l-LVEF. At a median follow-up of 15 months, there was no difference in MACCE and total mortality between patients who underwent CABG or PCI with p-LVEF and m-LVEF. CONCLUSION CABG was associated with higher in-hospital events. Hospital mortality in patients with l-LVEF was comparable between CABG and PCI. At 15 months' follow-up, PCI could have an advantage in decreasing MACCE in patients with l-LVEF.
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Affiliation(s)
- Amin Daoulah
- Department of Cardiovascular Medicine, King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Maryam Jameel Naser
- Department of Internal Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield, Springfield, Massachusetts, USA
| | - Ahmad S Hersi
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University, Riyadh
| | - Mohammed Alshehri
- Department of Cardiology, Prince Khaled Bin Sultan Cardiac Center, Khamis Mushait
| | - Turki Al Garni
- Department of Cardiology, Prince Sultan Cardiac Center, Riyadh
| | - Reda Abuelatta
- Department of Cardiology, Madinah Cardiac Center, Madinah, Kingdom of Saudi Arabia
| | - Nooraldaem Yousif
- Department of Cardiology, Mohammed Bin Khalifa Specialist Cardiac Center, Awali, Kingdom of Bahrain
| | - Wael Almahmeed
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, UAE
| | - Abdulaziz Alasmari
- Department of Cardiovascular Medicine, King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Alwaleed Aljohar
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University, Riyadh
| | - Badr Alzahrani
- Department of Cardiology, Prince Sultan Cardiac Center, Riyadh
| | - Bader K Abumelha
- Department of Family Medicine, King Abdulaziz Medical City, National Guard Hospital, Riyadh
| | - Mohamed Ajaz Ghani
- Department of Cardiology, Madinah Cardiac Center, Madinah, Kingdom of Saudi Arabia
| | - Haitham Amin
- Department of Cardiology, Mohammed Bin Khalifa Specialist Cardiac Center, Awali, Kingdom of Bahrain
| | | | | | | | - Wael Refaat
- Department of Cardiology, Prince Sultan Cardiac Center, Al Hassa
| | - Ehab Selim
- Department of Cardiology, Alhada Armed Forces Hospital, Taif
| | - Ahmed Jamjoom
- Department of Cardiovascular Medicine, King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Osama El-Sayed
- Department of Cardiovascular Medicine, King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Salem M Al-Faifi
- Department of Medicine, King Faisal Specialist Hospital & Research Center
| | - Maun N Feteih
- Department of Medicine, King Faisal Specialist Hospital & Research Center
| | - Ziad Dahdouh
- Department of Cardiovascular Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Jairam Aithal
- Department of Cardiology, Yas Clinic, Khalifa City A, Abu Dhabi, UAE
| | | | | | - Mohammed A Qutub
- Cardiology Center of Excellence, Department of Medicine, King Abdulaziz University, Jeddah
| | - Mohamed N Alama
- Cardiology Center of Excellence, Department of Medicine, King Abdulaziz University, Jeddah
| | | | - Taher Hassan
- Department of Cardiology, Bugshan General Hospital, Jeddah
| | - Mohammed Balghith
- King Abdulaziz Cardiac Center, College of Medicine, King Saud Bin Abdulaziz University for Health Science, Riyadh
| | | | | | - Osama Ahmad
- Department of Cardiovascular Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mohamed Ramadan
- Department of Cardiology, Prince Sultan Cardiac Center, Al Hassa
| | | | - Saif S Alshahrani
- Department of Emergency Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Wael Qenawi
- Department of Cardiology, Prince Khaled Bin Sultan Cardiac Center, Khamis Mushait
| | - Ahmed Shawky
- Department of Cardiology, Prince Khaled Bin Sultan Cardiac Center, Khamis Mushait
| | - Ahmed A Ghonim
- Cardiology Center of Excellence, Department of Medicine, King Abdulaziz University, Jeddah
| | - Ahmed Elmahrouk
- Department of Cardiovascular Medicine, King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia.,Department of Cardiothoracic Surgery, Tanta University, Tanta, Egypt
| | - Sameer Alhamid
- Department of Emergency Medicine, King Fahad Medical City
| | | | - Mamdouh M Haddara
- Department of Anesthesia, King Faisal Specialist Hospital & Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mina Iskandar
- Department of Internal Medicine-Pediatrics, University of Massachusetts Chan Medical School - Baystate, Springfield, Springfield, Massachusetts
| | - Abeer M Shawky
- Department of Cardiology, Dr Erfan and Bagedo General Hospital
| | - William T Hurley
- Department of Emergency Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Waleed A Ahmed
- Department of Internal Medicine, Security Forces Hospital, Mecca, Kingdom of Saudi Arabia
| | - Amir Lotfi
- Division of Cardiovascular Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield, Springfield, Massachusetts, USA
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Pei J, Wang X, Xing Z, Zheng K, Hu X. Short-term and long-term outcomes of revascularization interventions for patients with severely reduced left ventricular ejection fraction: a meta-analysis. ESC Heart Fail 2020; 8:634-643. [PMID: 33274612 PMCID: PMC7835572 DOI: 10.1002/ehf2.13141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/01/2020] [Accepted: 11/11/2020] [Indexed: 01/11/2023] Open
Abstract
AIMS This meta-analysis aimed to determine whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) should be preferred in patients with severely reduced left ventricular (LV) ejection fraction. METHODS AND RESULTS We searched the PubMed, EMBASE, and Cochrane Library databases from the conception of the databases till 1 May 2020 for studies on patients with severely reduced LV ejection fraction undergoing CABG and PCI. The primary clinical endpoints were 30 day and long-term mortalities. The secondary endpoints were 30 day and long-term incidences of myocardial infarction (MI) and stroke, long-term cardiovascular mortality, and repeat revascularization. Eighteen studies involving 11 686 patients were analysed. Compared with PCI, CABG had lower long-term mortality [hazard ratio (HR): 0.70, 95% confidence interval (CI): 0.61-0.80, P < 0.01], cardiovascular mortality (HR: 0.60, 95% CI: 0.43-0.85, P < 0.01), MI (HR: 0.51, 95% CI: 0.36-0.72, P < 0.01), and repeat revascularization (HR: 0.32, 95% CI: 0.23-0.47, P < 0.01) risk. Significant differences were not observed for long-term stroke (HR: 1.18, 95% CI: 0.74-1.87, P = 0.49), 30 day mortality (HR: 1.18, 95% CI: 0.89-1.56, P = 0.25), and MI (HR: 0.42, 95% CI: 0.16-1.11, P = 0.08) risk. CABG was associated with a higher risk of stroke within 30 days (HR: 2.88, 95% CI: 1.07-7.77, P = 0.04). In a subgroup analysis of propensity score-matched studies, CABG was associated with a higher long-term risk of stroke (HR: 1.61, 95% CI: 1.20-2.16, P < 0.01). CONCLUSIONS Among patients with severely reduced LV ejection fraction, CABG resulted in a lower mortality rate and an increased risk of stroke.
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Affiliation(s)
- Junyu Pei
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan, 410011, China
| | - Xiaopu Wang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan, 410011, China
| | - Zhenhua Xing
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan, 410011, China.,Department of Emergency Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Keyang Zheng
- Department of Cardiovascular Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xinqun Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan, 410011, China
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Gaudino M, Hameed I, Khan FM, Tam DY, Rahouma M, Yongle R, Naik A, Di Franco A, Demetres M, Petrie MC, Jolicoeur EM, Girardi LN, Fremes SE. Treatment strategies in ischaemic left ventricular dysfunction: a network meta-analysis. Eur J Cardiothorac Surg 2020; 59:ezaa319. [PMID: 33085752 DOI: 10.1093/ejcts/ezaa319] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/07/2020] [Accepted: 07/29/2020] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVES The optimal revascularization strategy for patients with ischaemic left ventricular systolic dysfunction (iLVSD) remains controversial. We aimed to compare percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical therapy (MT) in a network meta-analysis. METHODS All randomized controlled trials and observational studies comparing any combination of PCI, CABG and MT in patients with iLVSD were analysed in a frequentist network meta-analysis (generic inverse variance method). Primary outcome was mortality at longest available follow-up. Secondary outcomes were cardiac death, stroke, myocardial infarction (MI) and repeat revascularization (RR). RESULTS Twenty-three studies were included (n = 23 633; 4 randomized controlled trials). Compared to CABG, PCI was associated with higher mortality [incidence rate ratio (IRR) 1.32, 95% confidence interval (CI) 1.13-1.53], cardiac death (IRR 1.65, 95% CI 1.18-2.33), MI (IRR 2.18, 95% CI 1.70-2.80) and RR (IRR 3.75, 95% CI 2.89-4.85). Compared to CABG, MT was associated with higher mortality (IRR 1.52, 95% CI 1.26-1.84), cardiac death (IRR 3.83, 95% CI 2.12-6.91), MI (IRR 3.22, 95% CI 1.52-6.79) and RR (IRR 3.37, 95% CI 1.67-6.79). Compared to MT, PCI was associated with lower cardiac death (IRR 0.43, 95% CI 0.24-0.78). CABG ranked as the best revascularization strategy for mortality, cardiac death, MI and RR; MT ranked as the strategy associated with the lowest incidence of stroke. Left ventricular ejection fraction, year of study, use of drug-eluting stents did not affect relative treatment effects. CONCLUSIONS CABG appears to be the best therapy for iLVSD, although mainly based on observational data. Definitive randomized controlled trials comparing CABG and PCI in iLVSD are required. PROSPERO REGISTRATION ID 132414.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Faiza M Khan
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Derrick Y Tam
- Schulich Heart Centre, Sunnybrook Health Science University of Toronto, Toronto, ON, Canada
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Ruan Yongle
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Ajita Naik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell Medicine, New York, NY, USA
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Science University of Toronto, Toronto, ON, Canada
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7
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Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients with Left Ventricular Systolic Dysfunction. Cardiovasc Drugs Ther 2020; 35:575-585. [PMID: 32902738 DOI: 10.1007/s10557-020-07063-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE There is a paucity of comparative data examining the optimal revascularization strategy in patients with left ventricular systolic dysfunction (LVD). METHODS We performed an aggregate data meta-analysis of clinical outcomes comparing percutaneous coronary intervention (PCI) versus coronary artery bypass (CABG) in patients with LVD (left ventricle ejection fraction (LVEF) of ≤ 40%), using the random effects model. Effects size is reported as odds ratio (OR) and a 95% confidence interval. Outcomes included all-cause mortality, myocardial infarction, stroke, repeat revascularization, and a composite of major adverse cardiac and cerebrovascular events (MACCE) at 30-day, 3-year, and long-term (6.3 ± 0.9 years) follow-ups. Seventeen studies (16 observational, 1 randomized) and 18,599 patients (CABG 9651; PCI 8948) were included. RESULTS PCI and CABG had comparable all-cause mortality at 30 days (OR 0.78, 95% CI 0.49-1.23) and 3 years (OR 1.05, 95% CI 0.91-1.21); however, PCI was associated with increased long-term morality after a mean follow-up of 6.3 ± 0.9 years (31.6% vs. 24.3%, OR 1.41, 95% CI 1.21-1.64). A similar mortality trend was observed in the subgroup of patients with EF ≤ 35%. PCI had a higher rate of repeat revascularization at 3-year and long-term follow-ups. The long-term rates of stroke and MI were comparable. PCI, on the other hand, had lower rates of stroke at 30-day and 3-year follow-ups. CONCLUSION CABG was associated with lower rates of long-term mortality and revascularization but higher rate of upfront stroke in patients with LVD. However, the data included consisted predominantly of observational studies, highlighting the paucity and need for randomized trials.
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Sá MPBO, Perazzo ÁM, Saragiotto FAS, Cavalcanti LRP, Almeida ACE, Campos JCS, Braga PGB, Rayol SDC, Diniz RGS, Sá FBCA, Lima RC. Coronary Artery Bypass Graft Surgery Improves Survival Without Increasing the Risk of Stroke in Patients with Ischemic Heart Failure in Comparison to Percutaneous Coronary Intervention: A Meta-Analysis With 54,173 Patients. Braz J Cardiovasc Surg 2019; 34:396-405. [PMID: 31454193 PMCID: PMC6713365 DOI: 10.21470/1678-9741-2019-0170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Objective To evaluate whether there is any difference on the results of patients
treated with coronary artery bypass grafting (CABG) or percutaneous coronary
intervention (PCI) in the setting of ischemic heart failure (HF). Methods Databases (MEDLINE, Embase, Cochrane Controlled Trials Register
[CENTRAL/CCTR], ClinicalTrials.gov, Scientific Electronic
Library Online [SciELO], Literatura Latino-americana e do
Caribe em Ciências da Saúde [LILACS], and Google
Scholar) were searched for studies published until February 2019. Main
outcomes of interest were mortality, myocardial infarction, repeat
revascularization, and stroke. Results The search yielded 5,775 studies for inclusion. Of these, 20 articles were
analyzed, and their data were extracted. The total number of patients
included was 54,173, and those underwent CABG (N=29,075) or PCI (N=25098).
The hazard ratios (HRs) for mortality (HR 0.763; 95% confidence interval
[CI] 0.678-0.859; P<0.001), myocardial
infarction (HR 0.481; 95% CI 0.365-0.633; P<0.001), and
repeat revascularization (HR 0.321; 95% CI 0.241-0.428;
P<0.001) were lower in the CABG group than in the PCI
group. The HR for stroke showed no statistically significant difference
between the groups (random effect model: HR 0.879; 95% CI 0.625-1.237;
P=0.459). Conclusion This meta-analysis found that CABG surgery remains the best option for
patients with ischemic HF, without increase in the risk of stroke.
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Affiliation(s)
- Michel Pompeu Barros Oliveira Sá
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil.,Faculty of Medical Sciences and Biological Sciences Institute - FCM/ICB Nucleus of Postgraduate and Research in Health Sciences Recife Pernambuco Brazil Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Institute - FCM/ICB, Recife, Pernambuco, Brazil
| | - Álvaro Monteiro Perazzo
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil
| | - Felipe Augusto Santos Saragiotto
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil
| | - Luiz Rafael Pereira Cavalcanti
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil
| | - Antônio Carlos Escorel Almeida
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil
| | - Jéssica Cordeiro Siqueira Campos
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil
| | - Paulo Guilherme Bezerra Braga
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil
| | - Sérgio da Costa Rayol
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil
| | - Roberto Gouvea Silva Diniz
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil
| | - Frederico Browne Correia Araújo Sá
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil
| | - Ricardo Carvalho Lima
- Pronto Socorro Cardiológico de Pernambuco - PROCAPE Division of Cardiovascular Surgery Recife Pernambuco Brazil Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Pernambuco, Brazil.,University of Pernambuco - UPE Recife Pernambuco Brazil University of Pernambuco - UPE, Recife, Pernambuco, Brazil.,Faculty of Medical Sciences and Biological Sciences Institute - FCM/ICB Nucleus of Postgraduate and Research in Health Sciences Recife Pernambuco Brazil Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Institute - FCM/ICB, Recife, Pernambuco, Brazil
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