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Hara H, Takahashi K, Klaveren D, Ono M, Kawashima H, Kappetein P, Mohr F, Mack M, Holmes D, Morice M, Davierwala P, Head S, Thuijs D, Onuma Y, Serruys P. Ten-year all-cause death after percutaneous or surgical revascularization for men and women with multivessel or left main coronary artery disease: insights from the SYNTAX extended survival study. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
In patients with complex coronary artery disease (CAD), women favored coronary artery bypass grafting surgery (CABG) compared to percutaneous coronary intervention (PCI) at 5 years in the SYNTAX trial, whereas mortality rates after PCI and CABG were not different in men. On the other hand, poor outcomes of women undergoing PCI were not observed in the PRECOMBAT and BEST trials.
The long-term optimal revascularization strategy according to gender has not been fully evaluated.
Purpose
In the SYNTAX Extended Survival (SYNTAXES) study, no significant difference existed in all-cause death between PCI and CABG at 10 years. This study aimed to assess treatment effect of PCI and CABG for 10-year all-cause death according to gender.
Methods
The SYNTAXES study evaluated vital status up to 10 years in 1,800 patients with de novo three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD) randomized to treatment with CABG or PCI in the SYNTAX trial, and the pre-specified primary endpoint was all-cause death at 10 years. In this prespecified analysis, all-cause death at 10 years according to gender in patients undergoing PCI or CABG was evaluated.
Results
Of 1800 patients, 402 (22.3%) were women and 1398 (77.7%) were men. In women, the rate of mortality was significantly higher in the PCI arm at 5 years than in the CABG arm (19.3% vs. 10.3%; Log-rank p=0.010, Figure A), but the rates of mortality were not different at 10 years between the PCI and CABG arms (33.0% vs. 32.5%; Log-rank p=0.600, Figure A). In men, the mortality rate tended to be higher in the PCI arm at 10 years than in the CABG arm (27.0% vs. 22.5%; Log-rank p=0.082, Figure B), although the mortality rates were not different at 5 years between the PCI and CABG arms (12.4% vs. 12.3%; Log-rank p=0.957, Figure B).
Conclusion
The efficacy of CABG observed at 5 years disappeared at 10 years in women, whereas the efficacy of CABG became apparent after 5 years in men.
Figure 1
Funding Acknowledgement
Type of funding source: Public Institution(s). Main funding source(s): Erasmus University Medical Centre, Rotterdam, Netherlands, reference: MEC-2016-716
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Affiliation(s)
- H Hara
- Amsterdam UMC - Location Academic Medical Center, Amsterdam, Netherlands (The)
| | - K Takahashi
- Amsterdam UMC - Location Academic Medical Center, Amsterdam, Netherlands (The)
| | - D Klaveren
- Erasmus University Medical Centre, Rotterdam, Netherlands (The)
| | - M Ono
- Amsterdam UMC - Location Academic Medical Center, Amsterdam, Netherlands (The)
| | - H Kawashima
- Amsterdam UMC - Location Academic Medical Center, Amsterdam, Netherlands (The)
| | - P Kappetein
- Erasmus University Medical Centre, Rotterdam, Netherlands (The)
| | - F Mohr
- Heart Center of Leipzig, Leipzig, Germany
| | - M Mack
- Baylor University Medical Center, Dallas, United States of America
| | - D Holmes
- Mayo Clinic, Rochester, United States of America
| | - M Morice
- Jacques Cartier Private Hospital, Massy, France
| | | | - S Head
- Erasmus University Medical Centre, Rotterdam, Netherlands (The)
| | - D Thuijs
- Erasmus University Medical Centre, Rotterdam, Netherlands (The)
| | - Y Onuma
- National University of Ireland, Galway, Ireland
| | - P Serruys
- National University of Ireland, Galway, Ireland
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Hara H, Takahashi K, Ono M, Gao C, Wang R, Kappetein P, Mohr F, Mack M, Holmes D, Morice M, Davierwala P, Head S, Thuijs D, Onuma Y, Serruys P. Impact of periprocedural myocardial infarction on 10-year mortality after percutaneous coronary intervention or coronary artery bypass grafting for multivessel or left main coronary artery disease. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Periprocedural myocardial infarction (PMI) occurs frequently after both percutaneous coronary intervention (PCI) and bypass grafting surgery (CABG) in patients with complex coronary artery disease (CAD), and PMI has been shown to have a detrimental impact on mortality. On the other hand, long-term impact of PMI on mortality has not been fully evaluated.
Purpose
This study aimed to assess the impact of PMI according to SCAI definition on 10-year all-cause death in patients with complex CAD.
Methods
The SYNTAX Extended Survival (SYNTAXES) study evaluated vital status up to 10 years in 1800 patients with de novo three-vessel disease and/or left main coronary artery disease randomized to treatment with CABG or PCI in the SYNTAX trial. Blood was sampled for creatine kinase (CK) pre- and post-revascularisation, and the cardiac specific MB iso-enzyme (CK-MB) was determined only if the CK ratio ≥2 x the upper limit of normal (ULN). If the CK ratio <2 ULN, CK-MB assessment was not mandated. In this analysis, patients with at least one blood sampling within 48 hours of the procedure were included. PMI was defined as follows; peak CK-MB measured within 48 hours of the procedure ≥10 x ULN, or ≥5 x ULN with new Q-waves in 2 contiguous leads or new persistent left bundle branch block.
Results
Of 1800 patients, 1679 (93.2%) patients were included. Of 877 patients treated with PCI, PMI occurred in 26 patients (3.0%), whereas 14 (1.7%) PMIs were observed in 802 patients treated with CABG. Compared with patients without PMI, patients with PMI presented with unstable angina more frequently (45.0% vs. 28.7, p=0.033), and had a higher rate of bifurcation lesion (87.5% vs. 72.5, p=0.046). PMI was associated with a higher all-cause mortality at 10 years compared with no PMI (55.3% vs. 25.4%; Log-rank p<0.001, Figure), which was mainly driven by a high mortality rate within 1 year. In patients undergoing PCI, the mortality rates were significantly higher in patients with PMI not only within 1 year (Log-rank p<0.001) but also beyond one year (Log-rank p=0.016), compare to patients without PMI (Figure). On the other hand, in patients undergoing CABG, a higher mortality rate in patients with PMI was observed until 1 year (Log-rank p<0.001), but the impact of PMI on mortality beyond one year after CABG subsided (Log-rank p=0.308) (Figure 1).
Conclusion
PMI was associated with a poor prognosis at 10 years. The impact of PMI on mortality was strong within one year. Of note, the impact of PMI on mortality persisted beyond 1 year only in patients undergoing PCI. Patients who were treated with PCI and suffered PMI need careful follow-up beyond one year after revascularization.
Figure 1
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- H Hara
- Amsterdam UMC - Location Academic Medical Center, Amsterdam, Netherlands (The)
| | - K Takahashi
- Amsterdam UMC - Location Academic Medical Center, Amsterdam, Netherlands (The)
| | - M Ono
- Amsterdam UMC - Location Academic Medical Center, Amsterdam, Netherlands (The)
| | - C Gao
- University Hospital Nijmegen, Nijmegen, Netherlands (The)
| | - R Wang
- University Hospital Nijmegen, Nijmegen, Netherlands (The)
| | - P Kappetein
- Erasmus University Medical Centre, Rotterdam, Netherlands (The)
| | - F Mohr
- Heart Center of Leipzig, Leipzig, Germany
| | - M Mack
- Baylor University Medical Center, Dallas, United States of America
| | - D Holmes
- Mayo Clinic, Rochester, United States of America
| | - M Morice
- Jacques Cartier Private Hospital, Massy, France
| | | | - S Head
- Erasmus University Medical Centre, Rotterdam, Netherlands (The)
| | - D Thuijs
- Erasmus University Medical Centre, Rotterdam, Netherlands (The)
| | - Y Onuma
- National University of Ireland, Galway, Ireland
| | - P Serruys
- National University of Ireland, Galway, Ireland
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Ono M, Takahashi K, Hara H, Gao C, Wang R, Kappetein P, Mohr F, Mack M, Holmes D, Morice M, Davierwala P, Head S, Onuma Y, Thuijs D, Serruys P. Ten-year all-cause death in elderly patients undergoing percutaneous coronary intervention or coronary artery bypass grafting: a prespecified subgroup analysis of the SYNTAX Extended Survival study. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Coronary artery disease is the leading cause of death among elderly men and women worldwide. The aging society worldwide will lead to increasing numbers of elderly patients with multivessel coronary artery disease. Although age is recognized as one of the most important factors in a decision-making for revascularization of multivessel coronary artery disease, the very long-term outcomes in patients undergoing revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is still unclear.
Objectives
The aim of the present study was to investigate the association between revascularization strategies and 10-year outcomes in elderly patients.
Methods
The SYNTAX Extended Survival (SYNTAXES) study (NCT 03417050) is an investigator-driven extension of follow-up of a multicentre, randomised controlled trial done in 85 hospitals across 18 North American and European countries, enrolling 1,800 patients with de novo three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD) randomized to revascularization strategy with CABG versus PCI in the SYNTAX trial. Patients were divided into two groups according to the prespecified threshold of 70 years old; elderly patients (>70 years) and non-elderly patients (≤70 years). The primary endpoint of this study was all-cause death at 10 years.
Results
Out of 1,800 patients, 575 patients (31.9%) were classified as elderly (>70 years). The mean age ± standard deviation (SD) of the elderly patients and the non-elderly patients was 75.8±3.6 years and 60.1±7.4 years, respectively. Of note, elderly patients were more frequently female than non-elderly patients (33.6% vs. 17.1%, p<0.001). As expected, the elderly patients had higher prevalence of chronic kidney disease (43.4% vs. 7.9%, p<0.001), had higher anatomical SYNTAX score (30.2±11.8 vs 28.0±11.2 p<0.001) when compared to those of the non-elderly patients.
Up to 10 years, all-cause death occurred in 42.7% and 18.9% in the elderly and non-elderly patients, respectively (Log-rank p<0.001). The cubic spline curve showed an exponentially increase in all-cause death at 10 years according to the increase of age both in the PCI arm and the CABG arm. At 10 years, there was no significant difference in the risk of all-cause death between CABG vs. PCI either in elderly patients (41.5% vs. 44.0%; Log-rank p=0.53) or non-elderly patients (16.6% vs. 21.1%; Log-rank p=0.051).
Conclusion
CABG and PCI were equipoise in terms of risk of all-cause death at 10 years in patients with de novo 3VD and/or LMCAD irrespective of their age when stratified according to the prespecified threshold of 70 years old.
Kaplan-Meier curves
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): German Foundation of Heart Research
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Affiliation(s)
- M Ono
- Amsterdam UMC, Amsterdam, Netherlands (The)
| | | | - H Hara
- Amsterdam UMC, Amsterdam, Netherlands (The)
| | - C Gao
- Radboud University Medical Center, Department of Cardiology, Nijmegen, Netherlands (The)
| | - R Wang
- Radboud University Medical Center, Department of Cardiology, Nijmegen, Netherlands (The)
| | - P Kappetein
- Erasmus University Medical Centre, Department of Cardiothoracic Surgery, Rotterdam, Netherlands (The)
| | - F Mohr
- Heart Center of Leipzig, Department of Cardiac Surgery, Leipzig, Germany
| | - M Mack
- Baylor University Medical Center, Department of Cardiothoracic Surgery, Dallas, United States of America
| | - D Holmes
- Mayo Clinic, Department of Cardiovascular Diseases and Internal Medicine, Rochester, United States of America
| | - M Morice
- Jacques Cartier Private Hospital, Département of Cardiologie, Massy, France
| | - P Davierwala
- Heart Center of Leipzig, Department of Cardiac Surgery, Leipzig, Germany
| | - S Head
- Erasmus University Medical Centre, Department of Cardiothoracic Surgery, Rotterdam, Netherlands (The)
| | - Y Onuma
- National University of Ireland, Department of Cardiology, Galway, Ireland
| | - D Thuijs
- Erasmus University Medical Centre, Department of Cardiothoracic Surgery, Rotterdam, Netherlands (The)
| | - P Serruys
- Imperial College London, NHLI, London, United Kingdom
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Noack T, Thuijs D, Kappetein P, Serruys P, Mohr FW, Morice MC, Mack M, Holmes D, Davierwala P, Head S. Ten Year Survival after Coronary Artery Bypass Grafting versus Percutaneous Coronary Intervention: The SYNTAX Extended Survival (SYNTAXES) Study. Thorac Cardiovasc Surg 2020. [DOI: 10.1055/s-0040-1705342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Daniel W, Kieser T, Giammarco G, Trachiotis G, Puskas J, Kappetein P, Ruhparwar A, Jakob H, Head S, Taggart D. Intraoperative Transit-Time Flow Measurement in CABG: Insights from the Registry for Quality Assessment (RE-QUEST) Study. Thorac Cardiovasc Surg 2020. [DOI: 10.1055/s-0040-1705397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Rastan A, Boudriot E, Walther T, Falk V, Kappetein P, Serruys P, Doll N, Schuler G, Mohr FW. Frequency and pattern of multivessel and left main coronary artery disease – insights from a center specific SYNTAX study enrollment. Thorac Cardiovasc Surg 2007. [DOI: 10.1055/s-2007-967396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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