Percutaneous or surgical revascularization is associated with survival benefit in stable coronary artery disease

Abstract

Aims We assessed the association between early invasive therapy, burden of ischaemia, and survival benefit separately for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Ischaemia involving more than 10% of the left ventricular myocardium may identify patients who benefit from revascularization. However, it is not clear whether this association exists with both PCI and CABG. Materials and results Patients who underwent single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) between 1992 and 2012 were identified. Early revascularization was defined as PCI or CABG performed within 90 days of SPECT MPI. The association between early PCI or CABG and all-cause mortality was assessed using a doubly robust, propensity score matching analysis. In total, 54 522 patients were identified, with median follow-up 8.0 years. Early PCI was performed in 2688 patients and early CABG in 1228. In the matched cohorts, early revascularization was associated with improved survival compared to medical therapy in patients with more than 15% ischaemia for both PCI [adjusted hazard ratio (HR) 0.70, P = 0.002] and CABG (adjusted HR 0.73, P = 0.008). Conclusion In this observational analysis, both PCI and CABG were associated with reduced all-cause mortality in the presence of moderate to severe ischaemia after adjusting for factors leading to revascularization. As the threshold for improved outcomes with revascularization was similar for PCI and CABG, our results suggest that decisions for PCI vs. CABG for early revascularization should be determined by coronary anatomy, patient characteristics, and shared decision making, but not by the burden of ischaemia.

Surgical collateralization: The hidden mechanism for improving prognosis in chronic coronary syndromes

“…This notion may also explain our possibly conflicting report in which we demonstrate a survival benefit for PCI in a retrospective propensity-matched comparison with medical therapy once the amount of single photon emission computed tomography detected ischemia exceeded 15%. 32 This study is currently the only report demonstrating a survival impact for isolated PCI (not mixed with CABG) in chronic coronary syndromes. However, we were not able to provide information on CAD severity and the incidence of myocardial infarctions.…”

Visually estimated coronary artery calcium score improves SPECT-MPI risk stratification

“…SPECT-MPI was performed in two affiliated nuclear testing laboratories and the population included both outpatients and inpatients with suspected or known CAD. Patients who underwent early revascularization (revascularization within 90 days of SPECT MPI) were excluded (n = 304) because SPECT MPI results may influence the decision to pursue revascularization [1] , which may alter long-term outcomes [19] , [20] . The study was approved by University of Calgary Research Ethics Board (REB-ID ASD-7564), including waiver of consent.…”

Coronary Revascularization in Patients With Stable Coronary Artery Disease: The Role of Imaging

“…According to current clinical guidelines, revascularization should be indicated in patients with an ischemic burden > 10% of the LV (3). In a recent large observational study, the association between early PCI or CABG (performed <90 days from the first evaluation), the ischemic burden and all-cause mortality has been investigated in a large population of patients who underwent single-photon emission computed tomography (SPECT) myocardial perfusion imaging (19). At survival analysis, when patients were stratified according to the extent of ischemia, coronary revascularization (either with PCI or CABG) was associated with decreased mortality in patients with ischemia involving >15% of the myocardium.…”