| BackgroundCoronary disease severity is important for therapeutic decision-making and prognostication among patients presenting with Non-ST Elevation Acute Coronary Syndrome(NSTE-ACS).Previous study found High-Risk Coronary Anatomy(HRCA)to predict major adverse cardiovascular and cerebrovascular events(MACCEs)in 30 days and deaths in 1 year in NSTE-ACS patients undergoing Percutaneous Coronary Intervention(PCI).However,long-term outcome in patients undergoing PCI with HRCA is still unknown.ObjectiveWe aim to evaluate the long-term prognosis of NSTE-ACS patients with HRCA.MethodNSTE-ACS patients undergoing PCI in Fuwai Hospital in 2013 were prospectively enrolled and subsequently divided into HRCA and Low-Risk Coronary Anatomy(LRCA)group according to whether angiography complies with the HRCA definition.HRCA was defined as left main disease>50%,proximal LAD lesion>70%,or 2-to 3-vessel disease involving the LAD.Prognosis impact on 2-year MACCE and 5-year death/MI/revascularization/stroke is analyzed.ResultsOut of 4,984 enrolled patients with NSTE-ACS,3,752 patients belonged to HRCA group,while 1,232 patients belonged to LRCA group.Compared with LRCA group,patients in HRCA group had worse baseline characteristics including higher age,more comorbidities and worse angiographic findings.Patients in HRCA group had higher incidence of unplanned revascularization(2 years:9.7%vs.5.1%,p<0.001;5 years:15.4%vs.10.3%,p<0.001),2-year MACCE(13.1%vs.8.8%,p<0.001)and 5-year death/MI/revascularization/stroke(23.0%vs.18.4%,p=0.001).Kaplan-Meier survival analysis showed similar results.After adjusting for confounding factors,HRCA is independently associated with higher risk of revascularization(2 years:HR=1.636,95%CI:1.225-2.186;5 years:HR=1.460,95%CI:1.186-1.798),2-year MACCE(HR=1.275,95%CI=1.019-1.596,p=0.034)and 5-year death/MI/revascularization/stroke(HR=1.183,95%CI:1.010-1.385).ConclusionIn our large cohort of Chinese patients,HRCA is an independent risk factor for long-term unplanned revascularization and primary endpoints.BackgroundFor non-ST elevation acute coronary syndrome(NSTE-ACS)patients with multivessel coronary artery disease(MV-CAD),Percutaneous Coronary Intervention(PCI)has emerged as one of the routine means of management.In terms of index PCI procedures,we can either choose single-vessel PCI(SV-PCI)on the culprit lesion only,or perform one-stage multi vessel PCI(MV-PCI).The optimal strategy,however,remains controversial for NSTE-ACS patients with MV-CAD.On one hand,SV-PCI on only the culprit lesion leads to incomplete revascularization and might necessitate another staged PCI procedure.On the other hand,one-stage MV-PCI is associated with higher risk of procedural complications,undermining the efficacy and safety of intervention.AimThis study sought to compare long-term prognosis between SV-PCI and MV-PCI in patients with MV-CAD presenting with NSTE-ACS in a real-world population.MethodsThe present study is a post-hoc analysis of a large-scale,single-center,prospective cohort study.Patients who underwent PCI in Fuwai Hospital from January 2013 to December 2013 were consecutively enrolled.Patients presenting as NSTE-ACS were included in the current analysis and were grouped according to the PCI strategy at index procedure.SV-PCI was defined as targeting only the culprit vessel,whereas MV-PCI was defined as treating?1 coronary artery(s)in addition to the culprit vessel at the index procedure.The primary endpoint was the incidence of major adverse cardiovascular and cerebrovascular events(MACCE)at 2 years,consisting of all-cause death,cardiac death,myocardial infarction,unplanned revascularization,or stroke.Secondary endpoints are the individual components of MACCE,as well as stent thrombosis and bleeding.Multivariable Cox regression analysis was used to calculate hazard ratios(HRs)and 95%confidence intervals(CIs).To further reduce the effect of confounding factors,propensity score matching and inverse probability treatment weighting was performed.ResultsA total of 3,338 patients were included.SV-PCI and MV-PCI were performed in 2,259 patients and 1,079 patients,respectively.Baseline conditions are generally comparable between SV-PCI and MV-PCI group,except that MV-PCI patients were more likely to present with non-ST-segment elevation myocardial infarction,had higher body mass index,a lower rate of prior PCI,with ?-blockers and statins more frequently prescribed at discharge(all P<0.05).Patients in the MV-PCI group had higher pre-procedural SYNTAX scores and lower post-procedural SYNTAX scores(all P<0.05).Patients with MV-PCI were more likely to have complex anatomical characteristics,reflected by higher rates of tri-vessel disease,chronic total occlusion,bifurcation lesion,and ostial lesion compared with the SV-PCI group(all P<0.05).All patients completed 2-year follow-up,the MACCE rates and adjusted risk were not significantly different between the SV-PCI and MV-PCI groups(13.1%vs.14.0%,P=0.735;adjusted HR=0.967,95%CI:0.792-1.180).No significant difference was observed in the the cumulative incidence of all primary and secondary endpoints(all Log-rank P>0.05).Similar results were observed in propensity-score matching and inverse probability of treatment weighting analyses.Subgroup analysis revealed a consistent effect on 2-year MACCE across different subgroups.ConclusionIn NSTE-ACS patients with MV-CAD,MV-PCI is not superior to SV-PCI in terms of long-term MACCE.Future randomized controlled trials are needed to validate the findings of our study.BackgroundFor coronary artery disease patients with left main or multi vessel disease,current guidelines recommend Coronary Artery Bypass Grafting(CABG)over Percutaneous Coronary Intervention(PCI).In Non-ST Elevation Acute Coronary Syndrome(NSTE-ACS)patients with three vessel disease(TVD),however,no randomized studies have reported the long-term prognostic difference regarding patients receiving CABG,PCI or medical therapy(MT)only.The optimal treatment strategy for these patients is still under debate,partly due to a lack of real-world evidences with large sample size or long follow-up.AimThe aim of this study is to compare the long-term prognosis of NSTE-ACS patients with TVD who underwent PCI,CABG or MT.MethodsThis study is a secondary analysis derived from a large-sample,single-center,prospective,observational cohort study.From April 2004 to February 2011,the original cohort initially consecutively enrolled 8,943 patients with TVD hospitalized in Fuwai Hospital,Chinese Academy of Medical Sciences.In this analysis,we only included patients presenting as NSTE-ACS,consisting of Non-ST Elevation Myocardial Infarction(NSTEMI)and unstable angina(UA),and subsequently divided them into CABG,PCI and MT group according to the treatment they received.Median follow-up time was 7.5 years.The primary endpoint is all-cause death.The secondary endpoint is Major Adverse Cardiac and Cerebrovascular Events(MACCE),a composite of all-cause death,myocardial infarction(MI),stroke,or unplanned revascularization.ResultsAmong a total of 3,928 NSTE-ACS included in this study,1,589(40.5%)received PCI,1,230(31.3%)received CABG,while 27.9%received MT only.Compared with PCI group,patients in CABG and MT group had higher proportion of male,with more risk factors and comorbidities,including diabetes,prior MI,peripheral artery disease and chronic kidney disease.CABG group also had higher SYNTAX score and more left main disease,while MT group saw lower left ventricular ejection fraction(LVEF)and creatinine clearance.In terms of clinical outcomes,CABG group had significantly lower incidence of long-term MI,unplanned revascularization and MACCE,but higher incidence of stroke,compared with PCI group(all p<0.05).When compared with MT group,rate of all adverse events were lower in CABG and PCI group(all p<0.05),except for a similar rate of stroke and higher rate of MI and unplanned revascularization in PCI group.Kaplan-Meier survival analysis showed similar results.After adjusting for confounding factors with multivariable Cox regression analysis,CABG had significantly lower risk of long-term cardiac death(HR=0.445,95%CI:0.226-0.876),unplanned revascularzation(HR=0.330,95%CI:0.172-0.635)and MACCE(HR=0.719,95%CI:0.532-0.972)compared with PCI.In comparison with MT,PCI only significantly reduced risk of death,while CABG reduced risk of death,unplanned revascularization and MACCE.Subgroup analysis revealed consistent effect of CABG and PCI over the risk of all-cause death and MACCE across different subgroups,with no significant interactions.For PCI patients in which complete revascularization was achieved(CR-PCI),rate of long-term MI was still significantly higher than CABG(12.0%vs.2.7%,P<0.001),although no significant difference remained after adjustment of confounding factors(P>0.05).ConclusionIn NSTE-ACS patients with 3VD,CABG is independently associated with a lower risk of long-term cardiac death,revascularization and MACCE compared with PCI.Patients who received MT alone had the highest risk of long-term MACCE. |
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