Invasive Versus Medical Management in Patients With Prior Coronary Artery Bypass Surgery With a Non-ST Segment Elevation Acute Coronary Syndrome

Lee, Matthew M Y; Petrie, Mark C.; Rocchiccioli, Paul; Simpson, Joanne; Jackson, Colette E.; Corcoran, David; Mangion, Kenneth; Brown, Ammani; Cialdella, Pio; Sidik, Novalia; McEntegart, Margaret; Shaukat, Aadil; Rae, Alan P.; Hood, Stuart; Peat, Eileen; Findlay, Iain; Murphy, Clare; Cormack, Alistair; Bukov, Nikolay; Balachandran, Kanarath; Oldroyd, Keith G.; Ford, Ian; Wu, Olívia; McConnachie, Alex; Barry, Sarah; Berry, Colin

doi:10.1161/circinterventions.119.007830

Cited by 20 publications

(4 citation statements)

References 45 publications

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“…Moreover, the finding in the comparison of the randomised trial groups that health outcomes were not different with invasive management versus conservative management supports the notion that enrolment rates could be increased by education of physicians and patients. 21 Our trial results broadly reflect equipoise between the randomised strategies which should enhance confidence to support enrolment into a future randomised trial.…”

Section: Discussionsupporting

confidence: 57%

Invasive versus medically managed acute coronary syndromes with prior bypass (CABG-ACS): insights into the registry versus randomised trial populations

Lee¹,

Petrie²,

Rocchiccioli

et al. 2021

Open Heart

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BackgroundCoronary artery bypass graft (CABG) patients are under-represented in acute coronary syndrome (ACS) trials. We compared characteristics and outcomes for patients who did and did not participate in a randomised trial of invasive versus non-invasive management (CABG-ACS).MethodsACS patients with prior CABG in four hospitals were randomised to invasive or non-invasive management. Non-randomised patients entered a registry. Primary efficacy (composite of all-cause mortality, rehospitalisation for refractory ischaemia/angina, myocardial infarction (MI), heart failure) and safety outcomes (composite of bleeding, stroke, procedure-related MI, worsening renal function) were independently adjudicated.ResultsOf 217 patients screened, 84 (39%) screenfailed, of whom 24 (29%) did not consent and 60 (71%) were ineligible. Of 133 (61%) eligible, 60 (mean±SD age, 71±9 years, 72% male) entered the trial and 73 (age, 72±10 years, 73% male) entered a registry (preferences: physician (79%), patient (38%), both (21%)).Compared with trial participants, registry patients had more valve disease, lower haemoglobin, worse New York Heart Association class and higher frailty.At baseline, invasive management was performed in 52% and 49% trial and registry patients, respectively, of whom 32% and 36% had percutaneous coronary intervention at baseline, respectively (p=0.800). After 2 years follow-up (694 (median, IQR 558–841) days), primary efficacy (43% trial vs 49% registry (HR 1.14, 95% CI 0.69 to 1.89)) and safety outcomes (28% trial vs 22% registry (HR 0.74, 95% CI 0.37 to 1.46)) were similar. EuroQol was lower in registry patients at 1 year.ConclusionsCompared with trial participants, registry participants had excess morbidity, but longer-term outcomes were similar.Trial registration numberNCT01895751.

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Section: Discussionsupporting

confidence: 57%

Invasive versus medically managed acute coronary syndromes with prior bypass (CABG-ACS): insights into the registry versus randomised trial populations

Lee¹,

Petrie²,

Rocchiccioli

et al. 2021

Open Heart

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“…Patients with prior CABG have been excluded from many important clinical trials including VINO 32 and RITA3 24,[33][34][35][36] and only contributed to small numbers of patients in other ACS clinical trials (in OASIS-5: 1643 of 20,078 patients, in LIPSIA-NSTEMI: 41 of 600 patients, in Italian elderly ACS: 29 of 313, and in After Eighty Study: 76 of 457 patients). [37][38][39][40][41][42] Apart from a recently published pilot study where Lee et al 43 reported 12-month outcome data from 60 prior-CABG patients (invasive group, n¼31; medical group, n¼29), no major clinical trials exclusively examined clinical outcomes of an invasive versus medical approach in patients who presented with acute MI and had prior CABG. 40 In our study, only half of prior CABG patients underwent invasive coronary angiography.…”

Section: Discussionmentioning

confidence: 99%

Clinical Characteristics, Management Strategies and Outcomes of Acute Myocardial Infarction Patients With Prior Coronary Artery Bypass Grafting

Shoaib

Mohamed

Rashid

et al. 2021

Mayo Clinic Proceedings

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Objective: To investigate the management strategies, temporal trends, and clinical outcomes of patients with a history of coronary artery bypass graft (CABG) surgery and presenting with acute myocardial infarction (MI). Patients and Methods: We undertook a retrospective cohort study using the National Inpatient Sample database from the United States (January 2004eSeptember 2015), identified all inpatient MI admissions (7,250,768 records) and stratified according to history of CABG (group 1, CABG-naive [94%]; group 2, prior CABG [6%]). Results: Patients in group 2 were older, less likely to be female, had more comorbidities, and were more likely to present with non-ST-elevation myocardial infarction compared with group 1. More patients underwent coronary angiography (68% vs 48%) and percutaneous coronary intervention (PCI) (44% vs 26%) in group 1 compared with group 2. Following multivariable logistic regression analyses, the adjusted odd ratio (OR) of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.98; 95% CI, 0.95 to 1.005; P¼.11), all-cause mortality (OR, 1; 95% CI, 0.98 to 1.04; P¼.6) and major bleeding (OR, 0.99; 95% CI, 0.94 to 1.03; P¼.54) were similar to group 1. Lower adjusted odds of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.64; 95% CI, 0.57 to 0.72; P<.001), all-cause mortality (OR, 0.45; 95% CI, 0.38 to 0.53; P<.001), and acute ischemic stroke (OR, 0.71; 95% CI, 0.59 to 0.86; P<.001) were observed in group 2 patients who underwent PCI compared with those managed medically without any increased risk of major bleeding (OR, 1.08; 95% CI, 0.94 to 1.23; P¼.26). Conclusions: In this national cohort, MI patients with prior-CABG had a higher risk profile, but similar in-hospital adverse outcomes compared with CABG-naive patients. Prior-CABG patients who received PCI had better in-hospital clinical outcomes compared to those who received medical management.

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“…With advances in interventional therapy, most patients are treated aggressively. However, several randomized controlled trials (RCTs) failed to show appreciable benefits in reducing major cardiac events with the invasive strategy compared with the conservative management (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32). The invasive strategy also carries a certain risk for procedure-related myocardial infarction (MI) and a high risk of bleeding (20).…”

Section: Introductionmentioning

confidence: 99%

Comprehensive evaluation of time-varied outcomes for invasive and conservative strategies in patients with NSTE-ACS: a meta-analysis of randomized controlled trials

Zhao,

Sun,

Wang

et al. 2023

Front. Cardiovasc. Med.

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BackgroundResults from randomized controlled trials (RCTs) and meta-analyses comparing invasive and conservative strategies in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are highly debatable. We systematically evaluate the efficacy of invasive and conservative strategies in NSTE-ACS based on time-varied outcomes.MethodsThe RCTs for the invasive versus conservative strategies were identified by searching PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov. Trial data for studies with a minimum follow-up time of 30 days were included. We categorized the follow-up time into six varied periods, namely, ≤6 months, 1 year, 2 years, 3 years, 5 years, and ≥10 years. The time-varied outcomes were major adverse cardiovascular event (MACE), death, myocardial infarction (MI), rehospitalization, cardiovascular death, bleeding, in-hospital death, and in-hospital bleeding. Risk ratios (RRs) and 95% confidence intervals (Cis) were calculated. The random effects model was used.ResultsThis meta-analysis included 30 articles of 17 RCTs involving 12,331 participants. We found that the invasive strategy did not provide appreciable benefits for NSTE-ACS in terms of MACE, death, and cardiovascular death at all time points compared with the conservative strategy. Although the risk of MI was reduced within 6 months (RR 0.80, 95% CI 0.68–0.94) for the invasive strategy, no significant differences were observed in other periods. The invasive strategy reduced the rehospitalization rate within 6 months (RR 0.69, 95% CI 0.52–0.90), 1 year (RR 0.73, 95% CI 0.63–0.86), and 2 years (RR 0.77, 95% CI 0.60–1.00). Of note, an increased risk of bleeding (RR 1.80, 95% CI 1.28–2.54) and in-hospital bleeding (RR 2.17, 95% CI 1.52–3.10) was observed for the invasive strategy within 6 months. In subgroups stratified by high-risk features, the invasive strategy decreased MACE for patients aged ≥65 years within 6 months (RR 0.68, 95% CI 0.58–0.78) and 1 year (RR 0.75, 95% CI 0.62–0.91) and showed benefits for men within 6 months (RR 0.71, 95% CI 0.55–0.92). In other subgroups stratified according to diabetes, ST-segment deviation, and troponin levels, no significant differences were observed between the two strategies.ConclusionsAn invasive strategy is superior to a conservative strategy in reducing early events for MI and rehospitalizations, but the invasive strategy did not improve the prognosis in long-term outcomes for patients with NSTE-ACS.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289579, identifier PROSPERO 2021 CRD42021289579.

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Invasive Versus Medical Management in Patients With Prior Coronary Artery Bypass Surgery With a Non-ST Segment Elevation Acute Coronary Syndrome

Abstract: Supplemental Digital Content is available in the text.

Cited by 20 publications

References 45 publications

Invasive versus medically managed acute coronary syndromes with prior bypass (CABG-ACS): insights into the registry versus randomised trial populations

Invasive versus medically managed acute coronary syndromes with prior bypass (CABG-ACS): insights into the registry versus randomised trial populations

Clinical Characteristics, Management Strategies and Outcomes of Acute Myocardial Infarction Patients With Prior Coronary Artery Bypass Grafting

Comprehensive evaluation of time-varied outcomes for invasive and conservative strategies in patients with NSTE-ACS: a meta-analysis of randomized controlled trials

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