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

J Am Heart Assoc. 2021 Jan 5;10(1):e018104. doi: 10.1161/JAHA.120.018104. Epub 2020 Dec 19.

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 high-risk 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 long-term outcome compared with conservative therapy. As such, coronary anatomical profile should be considered when contemplating treatment for SIHD.

Keywords: coronary anatomy; revascularization; stable ischemic heart disease.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Conservative Treatment / adverse effects
  • Conservative Treatment / methods
  • Conservative Treatment / statistics & numerical data
  • Coronary Artery Bypass* / adverse effects
  • Coronary Artery Bypass* / methods
  • Coronary Artery Bypass* / statistics & numerical data
  • Coronary Vessels* / diagnostic imaging
  • Coronary Vessels* / pathology
  • Female
  • Humans
  • Long Term Adverse Effects* / diagnosis
  • Long Term Adverse Effects* / etiology
  • Long Term Adverse Effects* / prevention & control
  • Male
  • Myocardial Ischemia* / diagnosis
  • Myocardial Ischemia* / drug therapy
  • Myocardial Ischemia* / epidemiology
  • Myocardial Ischemia* / surgery
  • Patient Acuity
  • Patient Selection
  • Percutaneous Coronary Intervention* / adverse effects
  • Percutaneous Coronary Intervention* / methods
  • Percutaneous Coronary Intervention* / statistics & numerical data
  • Registries / statistics & numerical data
  • Risk Assessment / methods*
  • Time
  • Treatment Outcome
  • United States / epidemiology