Coronary anatomy and comorbidities impact on elective PCI outcomes in left main and multivessel coronary artery disease

Abstract

Introduction: The effects of coronary anatomy, lesion complexity, and comorbidities on outcomes of elective percutaneous coronary intervention (PCI) in high-risk patients with left main (LM) and/or multivessel coronary artery disease (CAD) are not well studied, as these patients are typically underrepresented in the clinical trials.Methods: This cohort study involved 33,568 consecutive elective PCI cases, excluding patients with prior coronary artery bypass graft, acute coronary syndrome within 24 hr of index PCI, or shock. All data were obtained from the New York State's PCI Reporting System from the calendar year 2015. In-hospital mortality was the primary outcome of study. Logistic regression models were built to calculate odds ratios (OR) with 95% confidence intervals (CI) for in-hospital mortality after adjustment for coronary anatomy and significant clinical comorbidities.Results: In this cohort of elective PCI cases all cause in-hospital mortality was low (0.3%), with a clear mortality gradient according to the extent of CAD: 0.1% in 1 vessel disease, 0.4% in 2 vessel, 0.5% in 3 vessel disease, and 3.2% in patients with LM CAD (p < .001). Mortality was also significantly increased in patients with multiple comorbidities: 0.1% in patients with 1 comorbidity, 0.7% with 2, 2.5% with 3, and 7.4% with 4 or more studied comorbidities (p < .0001). When adjusted for coronary anatomy and lesion complexity, having any 4 or more comorbidities was associated with significantly increased odds of dying after elective PCI (OR 25.9, 95% CI 8.152-82.063, p < .0001). Furthermore, when compared to patients with 3-vessel CAD, and accounted for comorbidities, the patients with LM disease still had significantly increased (OR 5.254, 95% CI 3.104-8.891, p < .0001) odds of dying after elective PCI. Conclusions:In patients undergoing elective PCI, multivessel CAD and particularly LM disease are associated with significantly increased all-cause mortality. Furthermore, when adjusted for the extent of CAD and lesion complexity, comorbidity burden remains an important predictor of mortality.

Nitrates as a Marker of Multiple Co-morbidities and Increased Mortality in Patients Undergoing Percutaneous Coronary Intervention (PCI)

“…In our cohort, nitrates were used more commonly in older patients with decreased LV ejection fraction, histories of stroke, PVD, CHF, ventricular arrhythmia, COPD, diabetes, kidney dysfunction, and more complex coronary anatomy. Thus, as suggested by other investigators, nitrate therapy may be an indicator of more advanced coronary disease and higher overall risk portending worse outcomes [ 28 , 29 ]. From a practical perspective, nitrates are added only in patients with continuing symptoms despite anti-platelet therapy, beta-adrenergic blockers, statins, and angiotensin-converting enzymes inhibitors.…”

Predictors of target lesion failure after treatment of left main, bifurcation, or chronic total occlusion lesions with ultrathin‐strut drug‐eluting coronary stents in the ULTRA registry

“…In our study, the higher TLF risk, as compared to non‐left main PCI, was mainly driven by cardiovascular mortality (9.4% vs. 2.7%), while other secondary endpoints such as TLR (4.3% vs. 4.3%) and TVR (6.5% vs. 6.2%) showed similar rates in both groups. Altogether, ultrathin‐strut DES may be considered a reasonable choice for treating left main lesions, although the stage of atherosclerotic disease that is reached by patients developing obstructive left main coronary disease is invariably associated with an unfavorable prognosis and usually characterizes patients with comorbidities which themselves lower the chance of long‐term survival 25,26 …”

“…Altogether, ultrathin-strut DES may be considered a reasonable choice for treating left main lesions, although the stage of atherosclerotic disease that is reached by patients developing obstructive left main coronary disease is invariably associated with an unfavorable prognosis and usually characterizes patients with comorbidities which themselves lower the chance of long-term survival. 25,26…”

A feasibility study of [18F]F-AraG positron emission tomography (PET) for cardiac imaging – myocardial viability in ischemia-reperfusion injury model

“…The success rate of these procedures, however, remains controversial due to lack of precise knowledge of tissue viability [ 3 ]. Besides, a significant risk is associated with such procedure especially in comorbid patients with multivessel coronary artery disease (CAD) [ 4 ]. Nevertheless, there is a notable improvement in patients with documented evidence of myocardial viability after revascularization [ 5 ].…”