Long-Term Clinical Outcomes Following Revascularization in High-Risk Coronary Anatomy Patients With Stable Ischemic Heart Disease

• Type of Material: Article
• Authors: Kevin R Bainey, University of Alberta; Wendimagegn Alemayehu, University of Alberta; Robert C Welsh, University of Alberta; Arnav Kumar, Emory University; Spencer King, Emory University; Ajay J Kirtane, Columbia University New York
• Language: English
• Date: 2021-01-05
• Publisher: WILEY
• Publication Version: Final Published Version
• Copyright Statement: © 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1161/JAHA.120.018104
• Title of Journal or Parent Work: JOURNAL OF THE AMERICAN HEART ASSOCIATION
• Volume: 10
• Issue: 1
• Start Page: 1
• End Page: 12
• Grant/Funding Information: The authors thank the Alberta Strategy for Patient Oriented Research (SPOR) Support Unit and Alberta Innovates for partial funding support.
• Keywords: INTERVENTION; 3-VESSEL DISEASE; SURVIVAL; TRIALS; stable ischemic heart disease; Science & Technology; BYPASS GRAFT-SURGERY; coronary anatomy; Cardiac & Cardiovascular Systems; SCORE; OPTIMAL MEDICAL THERAPY; revascularization; Cardiovascular System & Cardiology; Life Sciences & Biomedicine
• Research Categories: Health Sciences, Public Health; Health Sciences, Medicine and Surgery

Abstract

BACKGROUND: The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial failed to show a reduction in hard clinical end points with an early invasive strategy in stable ischemic heart disease (SIHD). However, the influence of left main disease and high-risk coronary anatomy was left unaddressed. In a large angiographic disease-based registry, we examined the modulating effect of revascularization on long-term outcomes in anatomically highrisk SIHD. METHODS AND RESULTS: 9016 patients with SIHD with high-risk coronary anatomy (3 vessel disease with ≥70% stenosis in all 3 epicardial vessels or left main disease ≥50% stenosis [isolated or in combination with other disease]) were selected for study from April 1, 2002 to March 31, 2016. The primary composite of all-cause death or myocardial infarction (MI) was compared between revascularization versus conservative management. A total of 5487 (61.0%) patients received revascularization with either coronary artery bypass graft surgery (n=3312) or percutaneous coronary intervention (n=2175), while 3529 (39.0%) patients were managed conservatively. Selection for coronary revascularization was associated with improved all-cause death/ MI as well as longer survival compared with selection for conservative management (Inverse Probability Weighted hazard ratio [IPW-HR] 0.62; 95% CI 0.58 to 0.66; P<0.001; IPW-HR 0.57; 95% CI 0.53-0.61; P<0.001, respectively). Similar risk reduction was noted with percutaneous coronary intervention (IPW-HR 0.64, 95% CI 0.59-0.70, P<0.001) and coronary artery bypass graft surgery (IPW-HR 0.61; 95% CI 0.57-0.66; P<0.001). CONCLUSIONS: Revascularization in patients with SIHD with high-risk coronary anatomy was associated with improved longterm outcome compared with conservative therapy. As such, coronary anatomical profile should be considered when contemplating treatment for SIHD.