Surgical and percutaneous revascularization outcomes based on SYNTAX I, II, and residual scores: a long-term follow-up study

Background

The objective of this study was to evaluate the association of SYNTAX scores I, II, and residual with cardiovascular outcomes of patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) and compare both procedures in a long-term follow-up.

Methods

This is a retrospective single-center study from the MASS registry at the Heart Institute of the University of São Paulo, Brazil in which 969 patients with stable coronary artery disease undergoing CABG (559) or PCI (410) were included. We assessed the SYNTAX scores I, II and residual in both interventions. Clinical endpoints were the first occurrence of a composite of overall death, myocardial infarction, stroke, or repeat revascularization (MACCE) and the total occurrence of each component of MACCE.

Results

In the CABG sample, SSI had a median of 23 (IQR 17–29.5), median SSII of 25.4 (IQR 19.2–32.8), and median rSS of 2 (IQR 0–6.5); in PCI SSI had a median of 14 (IQR 10–19.1), median SSII of 28.7 (IQR 23–34.2), and median rSS of 4.7 (IQR 0–9). Total of 174 events were documented and CABG patients had a lower rate of MACCE (15.6% vs. 21.2%; adjusted HR 1.98; 95% CI 1.13–3.47; P = 0.016) and repeat revascularization (3.8% vs. 11.5%; adjusted HR 4.35; CI 95% 1.74–10.85; P = 0.002) compared with PCI. No SYNTAX score tertile found a difference in death rate between procedures. In a multivariate analysis, the rSS was an independent predictor for MACCE (HR 1.04; 95% CI 1.01–1.06; P = 0.001). Regarding death, the only independent predictors were ejection fraction and renal function.

Conclusion

Surgical revascularization resulted in a more complete revascularization and lower rates of major cardiac or cerebrovascular events in a long-term follow-up. Also, grading the incompleteness of revascularization through the residual SYNTAX score identified a higher event rate, suggesting that complete revascularization is associated with a better prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01616-6.

Effect of diabetic kidney disease on therapeutic strategies for coronary artery disease: ten year follow-up

BACKGROUND

The best treatment for coronary artery disease (CAD) in patients with type 2 diabetes (DM2) and chronic kidney disease is unknown.

METHODS

This retrospective study included MASS registry patients with DM2 and multivessel CAD, stratified by kidney function. Primary endpoint was combined of mortality, myocardial infarction, or additional revascularization.

RESULTS

Median follow-up was 9.5 years. Primary endpoint occurrences among strata 1 and 2 were 53.4% and 40.7%, respectively (P=.020). Mortality rates were 37.4% and 24.6% in strata 1 and 2, respectively (P<.001). We observed a lower rate of major adverse cardiovascular events (MACE) (P=.027 for stratum 1 and P<.001 for stratum 2) and additional revascularization (P=.001 for stratum 1 and P<.001 for stratum 2) for those in the surgical group. In a multivariate analysis, eGFR was an independent predictor of MACE (P=.034) and mortality (P=.020).

CONCLUSIONS

Among subjects with DM2 and CAD the presence of lower eGFR rate was associated with higher rates of MACE and mortality, irrespective of treatment choice. CABG was associated with lower rates of MACE in both renal function strata. eGFR was an independent predictor of MACE and mortality in a 10-year follow-up.

Long-term outcomes of patients with stable coronary disease and chronic kidney dysfunction: 10-year follow-up of the Medicine, Angioplasty, or Surgery Study II Trial

BACKGROUND

Chronic kidney disease (CKD) is associated with a worse prognosis in patients with stable coronary artery disease (CAD); however, there is limited randomized data on long-term outcomes of CAD therapies in these patients. We evaluated long-term outcomes of CKD patients with CAD who underwent randomized therapy with medical treatment (MT) alone, percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG).

METHODS

Baseline estimated glomerular filtration rate (eGFR) was obtained in 611 patients randomized to one of three therapeutic strategies in the Medicine, Angioplasty, or Surgery Study II trial. Patients were categorized in preserved renal function and mild or moderate CKD groups depending on their eGFR (≥90, 89-60 and 59-30 mL/min/1.73 m2, respectively). The primary clinical endpoint, a composite of overall death and myocardial infarction, and its individual components were analyzed using proportional hazards regression (Clinical Trial registration information: http://www.controlled-trials.com. Registration number: ISRCTN66068876).

RESULTS

Of 611 patients, 112 (18%) had preserved eGFR, 349 (57%) mild dysfunction and 150 (25%) moderate dysfunction. The primary endpoint occurred in 29.5, 32.4 and 44.7% (P = 0.02) for preserved eGFR, mild CKD and moderate CKD, respectively. Overall mortality incidence was 18.7, 23.8 and 39.3% for preserved eGFR, mild CKD and moderate CKD, respectively (P = 0.001). For preserved eGFR, there was no significant difference in outcomes between therapies. For mild CKD, the primary event rate was 29.4% for PCI, 29.1% for CABG and 41.1% for MT (P = 0.006) [adjusted hazard ratio (HR) = 0.26, 95% confidence interval (CI) 0.07-0.88; P = 0.03 for PCI versus MT; and adjusted HR = 0.48; 95% CI 0.31-0.76; P = 0.002 for CABG versus MT]. We also observed higher mortality rates in the MT group (28.6%) compared with PCI (24.1%) and CABG (19.0%) groups (P = 0.015) among mild CKD subjects (adjusted HR = 0.44, 95% CI 0.25-0.76; P = 0.003 for CABG versus MT; adjusted HR = 0.56, 95% CI 0.07-4.28; P = 0.58 for PCI versus MT). Results were similar with moderate CKD group but did not achieve significance.

CONCLUSIONS

Coronary interventional therapy, both PCI and CABG, is associated with lower rates of events compared with MT in mild CKD patients >10 years of follow-up. More study is needed to confirm these benefits in moderate CKD.

P1835Application of SYNTAX score I, II and residual SYNTAX as predictors of long-term clinical outcomes after coronary artery bypass grafting

Background

The evaluation of coronary disease by SYNTAX score I (SSI) is used to grade coronary complexity. Following SSI, two other scores were developed: SYNTAX score II (SSII) and residual SYNTAX score (rSS). Nevertheless, there is still a lack of evidence about the prognostic significance of these scores among patients undergoing CABG.

Purpose

Our aim was to evaluate the relation of the SSI, SSII and rSS score with outcomes in a long-term follow-up after elective CABG.

Methods

This is a single center, registry-based study. Baseline SSI was calculated from patients undergoing CABG by interventional cardiologists. SSI results were considered as usual: <23, 23–32 and >32. SSII and rSRR were then calculated and categorized in tertiles: <21.4, 21.4–29.4 and >29.4 for SSII and 0, 1–5 and >5 for rSS. Primary outcome was a composite of overall death, myocardial infarction, additional revascularization, or stroke (MACCE).

Results

Data were obtained from 559 patients. Median follow-up was 6 years (IQR: 4.9–9.8) and 170 events were documented. The Kaplan-Meier curves (figure 1) showed significant differences of MACCE in higher SSI, SSII and rSS (p=0.039, 0.033, <0.001 respectively). After multivariate adjustment, rSS, ejection fraction (EF) and age were found to be independent predictors of MACCE (p<0.001, 0.034 and 0.006, respectively).

Figure 1

Conclusion

In this sample SSI, II and residual were associated with the occurrence of events. However, just the rSS remained an independent predictor of MACCE together with age and EF.

Dual platelet antiaggregation therapy after myocardial revascularization surgery

Coronary artery bypass graft (CABG) is a consolidated treatment in patients with coronary artery disease (CAD) for both symptom control and improvement of prognosis. The patency of venous grafts is still the most vulnerable point of the surgical treatment since it presents a high prevalence of occlusion both in the immediate postoperative period and in the long-term follow-up. Aspirin plays a well-established role in this setting, and for a long time, clopidogrel use has been restricted to patients allergic to aspirin. Recently, subgroup analyses of studies with different anti-platelet therapies have shown reduced mortality and cardiovascular events in patients on dual anti-platelet antiplatelet therapy (DAPT) undergoing CABG, although such studies have not been designed to evaluate this patient profile. However, there is still an insufficient number of randomized studies using DAPT in this context, resulting in a disagreement between the European and American cardiology societies guidelines regarding their indication and generating doubts in clinical practice.

Leptospirosis-associated acute kidney injury: penicillin at the late stage is still controversial

WHAT IS KNOWN AND OBJECTIVE

Some antimicrobial agents are active in vitro against Leptospiras. The use of penicillins at the late stage of leptospirosis is still controversial. We aimed to evaluate the use of penicillin in patients with leptospirosis-associated acute kidney injury (AKI).

METHODS

A retrospective study was conducted of patients with leptospirosis admitted to two hospitals in Fortaleza city, Brazil, between 1985 and 2008. AKI was defined according to the RIFLE and AKIN classifications. Patients were divided in two groups according to whether they were treated with a penicillin or not.

RESULTS

Two hundred and eighty-seven patients were included, with an average age of 36·8±15·6 years and mostly male (80·8%). One hundred and twelve patients (39%) received a penicillin. Patients treated with a penicillin were younger (32±14 years vs. 39±16 years, P=0·0002) and had a shorter hospital stay (8·4±5·0 vs. 11±7·7 days, P<0·0001). There was no difference in the onset of symptoms before hospital admission between the two groups (6·5±3·0 vs. 7·7±4·7, P=0·33). Systolic blood pressure was lower in the penicillin group (111±21 vs. 119±22 mmHg, P=0·04). AKI, need of dialysis and renal recovery at the time of hospital discharge were more frequent in patients who did not use a penicillin (P<0·05). Mortality was similar in both groups (11·6% vs. 13·7%, P=0·60).

CONCLUSION

Treatment of leptospirosis with antibiotics, including the penicillin, remains controversial. The main benefit of using penicillin in the present study was a reduction in the length of hospital stay and fewer complications, such as AKI, but its use was not associated with a decrease in mortality. On balance of risks and benefits, we recommend the use of penicillin in late-stage leptospirosis.