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Carvalho Ferreira AL, Garcez de Carvalho Feitoza LP, Cáceres Lessa AY, Chaves de Oliveira J, Chierici Pereira L, Benitez Gonzalez ME, Coelho Pessoa Lima AE, Ferreira Neves HA, Mota Guida C. Complete versus partial revascularization for older adults with acute coronary syndrome: a meta-analysis and systematic review of randomized and multivariable adjusted data. Coron Artery Dis 2024:00019501-990000000-00241. [PMID: 38829316 DOI: 10.1097/mca.0000000000001397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Evidence from randomized studies support complete over culprit-only revascularization for patients with acute coronary artery syndrome (ACS) and multivessel coronary artery diseases (MVD). Whether these findings extend to elderly patients, however, has not been thoroughly explored. METHODS We conducted a systematic review and meta-analysis comparing clinical outcomes of elderly individuals (defined as age ≥75 years) with ACS and MVD submitted to complete vs partial-only percutaneous coronary intervention (PCI). PubMed, Embase, and Cochrane were searched. We computed pooled hazard ratios with 95% confidence intervals (CI) to preserve time time-to-event data. RESULTS We included 7 studies, of which 2 were RCT and 5 were multivariable adjusted cohorts, comprising a total 10 147, of whom 43.8% underwent complete revascularization. As compared with partial-only PCI, complete revascularization was associated with a lower all-cause mortality (hazard ratio 0.71; 95% CI 0.60-0.85; P < 0.01), cardiovascular mortality (hazard ratio 0.64; 95% CI 0.52-0.79; P < 0.01), and recurrent myocardial infarction (hazard ratio 0.65; 95% CI 0.50-0.85; P < 0.01). There was no significant difference between groups regarding the risk of revascularizations (hazard ratio 0.80; 95% CI 0.53-1.20; P = 0.28). CONCLUSION Among elderly patients with ACS and multivessel CAD, complete revascularization is associated with a lower risk of all-cause mortality, cardiovascular mortality, and recurrent myocardial infarction.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Camila Mota Guida
- Department of Cardiology, Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
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2
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Lu YY, Lee CH, Chen CC, Chen DY, Ho MY, Yeh JK, Huang YC, Chang CY, Wang CY, Chang SH, Hsieh IC, Hsieh MJ. Comparison of long-term outcomes of complete vs. incomplete revascularization in elderly patients (≥75 years) with acute coronary syndrome and multi-vessel disease undergoing percutaneous coronary intervention. Front Cardiovasc Med 2023; 10:1037392. [PMID: 37560115 PMCID: PMC10407654 DOI: 10.3389/fcvm.2023.1037392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 06/26/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND The optimal revascularization strategy for elderly patients with acute coronary syndrome (ACS) remains uncertain. We evaluated the impact of complete revascularization (CR) vs. incomplete revascularization (IR) in elderly ACS patients with multivessel disease (MVD) undergoing percutaneous coronary intervention (PCI). METHODS Using registry data from 2011 to 2019, we conducted a propensity-score matched cohort study. Elderly patients (≥75 years) with ACS and MVD who underwent PCI were divided into CR and IR groups based on angiography during index hospitalization. Major adverse cardiovascular events (MACEs), including all-cause mortality, recurrent non-fatal myocardial infarction, and any revascularization, were assessed at 3-year follow-up. RESULTS Among 1,018 enrolled patients, 496 (48.7%) underwent CR and 522 (51.3%) received IR. After 1:1 propensity-score matching, we analyzed 395 pairs. At 3-year follow-up, CR was significantly associated with lower MACE risk compared to IR (16.7% vs. 25.6%, HR = 0.65, 95% CI: 0.47-0.88, p = 0.006), driven by reduced all-cause mortality. This benefit was consistent across all pre-specified subgroups, particularly in ST segment elevation (STE)-ACS patients. In non-STE (NSTE)-ACS subgroup analysis, CR was also associated with a lower risk of cardiac mortality compared to IR (HR = 0.30, 95% CI: 0.12-0.75, p = 0.01). CONCLUSION In elderly ACS patients with MVD undergoing PCI, CR demonstrates superior long-term outcomes compared to IR, irrespective of STE- or NSTE-ACS presentation.
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Affiliation(s)
- Yu-Ying Lu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Hung Lee
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Chi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Dong-Yi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Yun Ho
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jih-Kai Yeh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chang Huang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chieh-Yu Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chao-Yung Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Center for Big Data Analytics and Statistics, Department of Medical Research and Development, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Jer Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Khambholja K, Gehani M. Use of Structured Template and Reporting Tool for Real-World Evidence for Critical Appraisal of the Quality of Reporting of Real-World Evidence Studies: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:427-434. [PMID: 36210293 DOI: 10.1016/j.jval.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Real-world evidence (RWE) studies are increasingly being used to support healthcare decisions. Various frameworks, tools, and checklists exist for ensuring quality of real-world data, designing robust studies, and assessing potential for bias. In January 2021, Structured Template and Reporting Tool for RWE (STaRT-RWE) was released to further reduce ambiguity, assumptions, and misinterpretation while planning, implementing, and reporting RWE studies of the safety and effectiveness of treatments. The objective of this study was to identify gaps in the reporting quality of published RWE studies by using this template for critical appraisal. METHODS Two reviewers conducted a keyword search on PubMed for free-full-text research articles using real-world data, RWE design, and safety with or without effectiveness outcomes of a medicinal product or intervention in humans of any age or gender, published in English between January 13, 2021, and January 13, 2022. Assessment of risk of bias was done using Assessment of Real-World Observational Studies critical appraisal tool. Deficiencies in methods and findings as per STaRT-RWE template were reported as frequencies. RESULTS A total of 54 of 2374 retrieved studies were included in the review. Based on the STaRT-RWE template, the studies inadequately reported empirically defined covariates, power and sample size calculation, attrition, sensitivity analyses, index date (day 0) defining criterion, predefined covariates, outcome, metadata about data source and software, objective, inclusion and exclusion criteria, analysis specifications, and follow-up. CONCLUSIONS The use of STaRT-RWE template along with its tables, design diagram, and library of published studies has a potential of improving robustness of RWE studies.
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Affiliation(s)
- Kapil Khambholja
- Department of Medical Writing and Real World Evidence, Genpro Research Inc, Waltham, MA, USA.
| | - Manish Gehani
- Department of Medical Writing and Real World Evidence, Genpro Research Pvt Ltd, Thiruvananthapuram, India
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Marino M, Digiacomo S, Cacucci M, Catanoso A, Valentini P, Landolina M. Complete Percutaneous Revascularization in Patients Aged ≥85 Years With Acute Coronary Syndrome and Multivessel Coronary Artery Disease. Am J Cardiol 2022; 180:10-16. [PMID: 35906125 DOI: 10.1016/j.amjcard.2022.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 11/25/2022]
Abstract
Multivessel coronary disease is frequent in older patients who underwent coronary angiography for acute coronary syndrome. Whether a complete revascularization or a culprit-only approach is preferable in these patients is still debated. We included consecutive patients aged ≥85 years, presenting with acute coronary syndrome and showing multivessel coronary disease at coronary angiography. Patients were grouped according to complete (residual SYNTAX score [RSS] 0 to 8) or incomplete (RSS >8) revascularization. Primary end point was the rate of major adverse cardiovascular events (MACEs, the composite of cardiovascular death, re-myocardial infarction [re-MI], clinically driven percutaneous coronary intervention, and rehospitalization because of cardiac disease) at 2 years follow-up. A total of 166 patients met the criteria for enrollment; 108 patients had a final RSS 0 to 8 (complete revascularization) and 58 patients had a final RSS >8 (incomplete revascularization). The rate of MACE was reduced in patients who underwent complete revascularization (35.2% vs 51.7%, p = 0.039, adjusted hazard ratio 0.60, 95% confidence interval 0.37 to 0.98, p = 0.04), a difference mainly driven by a reduction in re-MI (8.3% vs 19.0%, p = 0.045), clinically driven percutaneous coronary intervention (2.8% vs 19.0%, p <0.001), and rehospitalization for cardiac disease (9.3% vs 24.1%, p = 0.009). Other independent predictors of MACE were active malignancy, previous MI, left ventricle ejection fraction <35% (increasing risk of events), and radial access (reducing risk of events). In conclusion, in patients aged ≥85 years, a complete revascularization is associated with a better prognosis, especially in terms of nonfatal events.
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Affiliation(s)
| | - Simonluca Digiacomo
- Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Policlinico San Marco, Zingonia, Italy
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5
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Biscaglia S, Erriquez A, Serenelli M, D'Ascenzo F, De Ferrari G, Ariza Sole A, Sanchis J, Giannini F, Gallo F, Scala A, Menozzi A, Pighi M, Moreno R, Iannopollo G, Menozzi M, Guiducci V, Tebaldi M, Campo G. Complete versus culprit-only strategy in older MI patients with multivessel disease. Catheter Cardiovasc Interv 2022; 99:970-978. [PMID: 35170844 DOI: 10.1002/ccd.30075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 12/26/2021] [Indexed: 11/08/2022]
Abstract
AIMS The revascularization strategy to pursue in older myocardial infarction (MI) patients with multivessel disease (MVD) is currently unknown. For this reason, while waiting for the results of dedicated trials, we sought to compare a complete versus a culprit-only strategy in older MI patients by merging data from four registries. METHODS AND RESULTS The inclusion criteria for the target population of the present study were (i) age ≥ 75 years; (ii) MI (STE or NSTE); (iii) MVD; (iv) successful treatment of culprit lesion. Propensity scores (PS) were derived using logistic regression (backward stepwise selection, p < 0.2). The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular (CV) death, MI, and major bleeding. Multivariable adjustment included the PS and inverse probability of treatment weighting (IPTW). The Kaplan-Meier plots were weighted for IPT. Among 2087 patients included, 1362 (65%) received culprit-only treatment whereas 725 (35%) complete revascularization. The mean age was 81.5 years, while the mean follow-up was 419 ± 284 days. Seventy-four patients (10%) died in the complete group and 223 in the culprit-only one (16%). The adjusted cumulative 1-year mortality was 9.7% in the complete and 12.9% in the culprit-only group (adjusted HR: 0.67, 95% CI: 0.50-0.89). Complete revascularization was associated with lower incidence of CV death (adjusted HR: 0.68, 95% CI: 0.48-0.95) and MI (adjusted HR 0.67, 95% CI: 0.48-0.95). CONCLUSIONS Culprit-only is the default strategy in older MI patients with MVD. In our analysis, complete revascularization was associated with lower all-cause and CV mortality and with a lower MI rate.
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Affiliation(s)
- Simone Biscaglia
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Ferrara, Italy
| | - Andrea Erriquez
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Ferrara, Italy
| | - Matteo Serenelli
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Ferrara, Italy
| | - Fabrizio D'Ascenzo
- Cardiology Department, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Gaetano De Ferrari
- Cardiology Department, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Albert Ariza Sole
- Cardiology Department, Bellvitge University Hospital. L'Hospitalet de Llobregat, Barcelona, Spain
| | - Juan Sanchis
- Cardiology Department, University Clinic Hospital of Valencia, INCLIVA, University of Valencia, CIBERCV, Valencia, Spain
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care & Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Francesco Gallo
- Interventional Cardiology, Ospedale dell'Angelo, Venezia, Venice, Italy
| | - Antonella Scala
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Ferrara, Italy
| | - Alberto Menozzi
- S.C. Cardiologia, Ospedale Sant'Andrea, ASL5 Liguria, La Spezia, Liguria, Italy
| | - Michele Pighi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Raul Moreno
- Interventional Cardiology, University Hospital La Paz, Madrid, Spain
| | | | - Mila Menozzi
- Cardiovascular Department, Infermi Hospital, Rimini, Italy
| | - Vincenzo Guiducci
- Cardiology Unit, Azienda USL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Ferrara, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Ferrara, Italy
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García-Blas S, Cordero A, Diez-Villanueva P, Martinez-Avial M, Ayesta A, Ariza-Solé A, Mateus-Porta G, Martínez-Sellés M, Escribano D, Gabaldon-Perez A, Bodi V, Bonanad C. Acute Coronary Syndrome in the Older Patient. J Clin Med 2021; 10:jcm10184132. [PMID: 34575243 PMCID: PMC8467899 DOI: 10.3390/jcm10184132] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 01/21/2023] Open
Abstract
Coronary artery disease is one of the leading causes of morbidity and mortality, and its prevalence increases with age. The growing number of older patients and their differential characteristics make its management a challenge in clinical practice. The aim of this review is to summarize the state-of-the-art in diagnosis and treatment of acute coronary syndromes in this subgroup of patients. This comprises peculiarities of ST-segment elevation myocardial infarction (STEMI) management, updated evidence of non-STEMI therapeutic strategies, individualization of antiplatelet treatment (weighting ischemic and hemorrhagic risks), as well as assessment of geriatric conditions and ethical issues in decision making.
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Affiliation(s)
- Sergio García-Blas
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
| | - Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain
| | - Pablo Diez-Villanueva
- Cardiology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (P.D.-V.); (M.M.-A.)
| | - Maria Martinez-Avial
- Cardiology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (P.D.-V.); (M.M.-A.)
| | - Ana Ayesta
- Cardiology Department, Hospital Central de Asturias, 33011 Oviedo, Spain;
| | - Albert Ariza-Solé
- Cardiology Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.A.-S.); (G.M.-P.)
| | - Gemma Mateus-Porta
- Cardiology Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.A.-S.); (G.M.-P.)
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, 28007 Madrid, Spain
| | - David Escribano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain
| | - Ana Gabaldon-Perez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
| | - Vicente Bodi
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
- Correspondence:
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