Comparison of Long-term Outcomes in Patients with Premature Triple-vessel Coronary Disease Undergoing Three Different Treatment Strategies: A Prospective Cohort Study

Jing-Jing Xu, Yin Zhang, Lin Jiang, Jian Tian, Lei Song, Zhan Gao, Xin-Xing Feng, Xue-Yan Zhao, Yan-Yan Zhao, Dong Wang, Kai Sun, Lian-Jun Xu, Ru Liu, Run-Lin Gao, Bo Xu, Lei Song, Jin-Qing Yuan, Jing-Jing Xu, Yin Zhang, Lin Jiang, Jian Tian, Lei Song, Zhan Gao, Xin-Xing Feng, Xue-Yan Zhao, Yan-Yan Zhao, Dong Wang, Kai Sun, Lian-Jun Xu, Ru Liu, Run-Lin Gao, Bo Xu, Lei Song, Jin-Qing Yuan

Abstract

Background: Patients with premature triple-vessel disease (PTVD) have a higher risk of recurrent coronary events and repeat revascularization; however, the long-term outcome of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and medical therapy (MT) alone for PTVD patients is controversial. The aim of this study is to evaluate the long-term outcome of PTVD patients among these three treatment strategies, to find out the most appropriate treatment methods for these patients.

Methods: One thousand seven hundred and ninety-two patients with PTVD (age: men ≤50 years and women ≤60 years) were enrolled between 2004 and 2011. The primary end point was all-cause death. The secondary end points were cardiac death, myocardial infarction, stroke, or repeat revascularization.

Results: PCI, CABG, and MT alone were performed in 933 (52.1%), 459 (25.6%), and 400 (22.3%) patients. Both PCI and CABG were associated with lower all-cause death (4.6% vs. 4.1% vs. 15.5%, respectively, P < 0.01) and cardiac death (2.8% vs. 2.0% vs. 9.8%, respectively, P < 0.01) versus MT alone. The rate of repeat revascularization in the CABG group was significantly lower than those in the PCI and MT groups. After adjusting for baseline factors, PCI and CABG were still associated with similar lower risk of all-cause death and cardiac death versus MT alone (all-cause death: hazard ratio [HR]: 0.35, 95% confidence interval [CI]: 0.23-0.53, P < 0.01 and HR: 0.35, 95% CI: 0.18-0.70, P = 0.003, respectively, and cardiac death: HR: 0.32, 95% CI: 0.19-0.54, P < 0.01 and HR: 0.36, 95% CI: 0.14-0.93, P = 0.03, respectively).

Conclusions: PCI and CABG provided equal long-term benefits for all-cause death and cardiac death for PTVD patients. Patients undergoing MT alone had the worst long-term clinical outcomes.

Trial registration: ClinicalTrials.gov; Identifier: NCT02634086. https://www.clinicaltrials.gov/ct2/show/record/NCT02634086?term=NCT02634086&rank=1.

Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
Flow chart of this study. TVD: Triple-vessel disease; CABG: Coronary artery bypass grafting; PCI: Percutaneous coronary intervention; MT: Medical therapy.
Figure 2
Figure 2
Kaplan-Meier Survival curve among CABG, PCI, and MT alone (a-f). No difference in all-cause death and cardiac death were found between the PCI and CABG groups (a and c). The incidence of myocardial infarction was lower in the CABG and MT alone groups than that in the PCI group (d). The rate of repeat revascularization was significantly lower in the CABG group compared with the PCI and MT groups (e). There was no significant difference for stroke when comparing the three groups (f). CABG: Coronary artery bypass graft; PCI: Percutaneous coronary intervention; MT: Medical therapy.
Figure 3
Figure 3
Subgroup analysis of all-cause mortality. No significant difference was found between the PCI and CABG groups for the risk of all-cause mortality (a). This risk was lower in both the PCI and CABG groups compared with MT alone except for the subgroups with LVEF 32 (b and c). DM: Diabetes mellitus; MI: Myocardial infarction; PCI: Percutaneous coronary intervention; CABG: Coronary artery bypass graft; MT: Medical therapy; LVEF: Left ventricular ejection fraction; SYNTAX: Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery.

References

    1. Meliga E, De Benedictis M, Gagnor A, Belli R, Scrocca I, Lombardi P, et al. Long-term outcomes of percutaneous coronary interventions with stent implantation in patients ≤40 years old. Am J Cardiol. 2012;109:1717–21. doi: 10.1016/j.amjcard.2012.01.400.
    1. Sadeghi R, Adnani N, Erfanifar A, Gachkar L, Maghsoomi Z. Premature coronary heart disease and traditional risk factors-can we do better. Int Cardiovasc Res J. 2013;7:46–50.
    1. Reddy SM, Byrapaneni RB, Rangappa C, Gouni UK, Vakati C, Suryavanshi S, et al. Surgical revascularization for premature coronary artery disease in second and third decade of life. Interact Cardiovasc Thorac Surg. 2017;24:99–101. doi: 10.1093/icvts/ivw295.
    1. Do R, Stitziel NO, Won HH, Jørgensen AB, Duga S, Angelica Merlini P, et al. Exome sequencing identifies rare LDLR and APOA5 alleles conferring risk for myocardial infarction. Nature. 2015;518:102–6. doi: 10.1038/nature13917.
    1. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360:961–72. doi: 10.1056/NEJMoa0804626.
    1. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;58:e123–210. doi: 10.1016/j.jacc.2011.08.009.
    1. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–122. doi: 10.1016/j.jacc.2011.08.007.
    1. Task Force Members, Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The task force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34:2949–3003. doi: 10.1093/eurheartj/eht296.
    1. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE, Jr, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012;60:645–81. doi: 10.1016/j.jacc.2012.06.004.
    1. Lautamäki A, Airaksinen KE, Kiviniemi T, Vinco G, Ribichini F, Gunn J, et al. Prognosis and disease progression in patients under 50 years old undergoing PCI: The CRAGS (Coronary aRtery diseAse in younG adultS) study. Atherosclerosis. 2014;235:483–7. doi: 10.1016/j.atherosclerosis.2014.05.953.
    1. Biancari F, Onorati F, Faggian G, Heikkinen J, Anttila V, Jeppsson A, et al. Determinants of outcome after isolated coronary artery bypass grafting in patients aged ≤50 years (from the coronary aRtery diseAse in younG adultS study) Am J Cardiol. 2014;113:275–8. doi: 10.1016/j.amjcard.2013.08.038.
    1. Serruys PW, Ong AT, van Herwerden LA, Sousa JE, Jatene A, Bonnier JJ, et al. Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: The final analysis of the arterial revascularization therapies study (ARTS) randomized trial. J Am Coll Cardiol. 2005;46:575–81. doi: 10.1016/j.jacc.2004.12.082.
    1. Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367:2375–84. doi: 10.1056/NEJMoa1211585.
    1. Serruys PW, Onuma Y, Garg S, Vranckx P, De Bruyne B, Morice MC, et al. 5-year clinical outcomes of the ARTS II (Arterial Revascularization Therapies Study II) of the sirolimus-eluting stent in the treatment of patients with multivessel de novo coronary artery lesions. J Am Coll Cardiol. 2010;55:1093–101. doi: 10.1016/j.jacc.2009.11.049.
    1. Yan TD, Padang R, Poh C, Cao C, Wilson MK, Bannon PG, et al. Drug-eluting stents versus coronary artery bypass grafting for the treatment of coronary artery disease: A meta-analysis of randomized and nonrandomized studies. J Thorac Cardiovasc Surg. 2011;141:1134–44. doi: 10.1016/j.jtcvs.2010.07.001.
    1. Rodriguez AE, Grinfeld L, Fernandez-Pereira C, Mieres J, Rodriguez Alemparte M, Berrocal D, et al. Revascularization strategies of coronary multiple vessel disease in the Drug Eluting Stent Era: One year follow-up results of the ERACI III trial. EuroIntervention. 2006;2:53–60.
    1. Brener SJ, Lytle BW, Casserly IP, Schneider JP, Topol EJ, Lauer MS, et al. Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features. Circulation. 2004;109:2290–5. doi: 10.1161/01.CIR.0000126826.58526.14.
    1. Vieira RD, Hueb W, Gersh BJ, Lima EG, Pereira AC, Rezende PC, et al. Effect of complete revascularization on 10-year survival of patients with stable multivessel coronary artery disease: MASS II trial. Circulation. 2012;126:S158–63. doi: 10.1161/CIRCULATIONAHA.111.084236.
    1. Bangalore S, Guo Y, Samadashvili Z, Blecker S, Hannan EL. Revascularization in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction: Everolimus-eluting stents versus coronary artery bypass graft surgery. Circulation. 2016;133:2132–40. doi: 10.1161/CIRCULATIONAHA.115.021168.
    1. Deb S, Wijeysundera HC, Ko DT, Tsubota H, Hill S, Fremes SE, et al. Coronary artery bypass graft surgery vs.percutaneous interventions in coronary revascularization: A systematic review. JAMA. 2013;310:2086–95. doi: 10.1001/jama.2013.281718.
    1. Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013;381:629–38. doi: 10.1016/S0140-6736(13)60141-5.
    1. He JQ, Yu XP, Peng C, Li Q, Luo YW, Gao YC, et al. Predictive ability of the SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery score II for long-term mortality in patients with three-vessel coronary artery disease undergoing percutaneous coronary intervention treated with second-generation drug-eluting stents. Chin Med J. 2015;128:2176–82. doi: 10.4103/0366-6999.162510.
    1. Fanari Z, Weiss SA, Zhang W, Sonnad SS, Weintraub WS. Comparison of percutaneous coronary intervention with drug eluting stents versus coronary artery bypass grafting in patients with multivessel coronary artery disease: Meta-analysis of six randomized controlled trials. Cardiovasc Revasc Med. 2015;16:70–7. doi: 10.1016/j.carrev.2015.01.002.
    1. Habib RH, Dimitrova KR, Badour SA, Yammine MB, El-Hage-Sleiman AK, Hoffman DM, et al. CABG versus PCI: Greater benefit in long-term outcomes with multiple arterial bypass grafting. J Am Coll Cardiol. 2015;66:1417–27. doi: 10.1016/j.jacc.2015.07.060.
    1. Park SJ, Ahn JM, Kim YH, Park DW, Yun SC, Lee JY, et al. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med. 2015;372:1204–12. doi: 10.1056/NEJMoa1415447.
    1. Norris DM, Anderson JR. Statin loading before percutaneous coronary intervention to reduce periprocedural myocardial infarction. Cardiol Rev. 2012;20:319–24. doi: 10.1097/CRD.0b013e31826db7ff.
    1. Athappan G, Chacko P, Patvardhan E, Gajulapalli RD, Tuzcu EM, Kapadia SR, et al. Late stroke: Comparison of percutaneous coronary intervention versus coronary artery bypass grafting in patients with multivessel disease and unprotected left main disease: A meta-analysis and review of literature. Stroke. 2014;45:185–93. doi: 10.1161/STROKEAHA.113.003323.
    1. Palmerini T, Biondi-Zoccai G, Reggiani LB, Sangiorgi D, Alessi L, De Servi S, et al. Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention. J Am Coll Cardiol. 2012;60:798–805. doi: 10.1016/j.jacc.2011.10.912.
    1. Alam M, Virani SS, Shahzad SA, Siddiqui S, Siddiqui KH, Mumtaz SA, et al. Comparison by meta-analysis of percutaneous coronary intervention versus coronary artery bypass grafting in patients with a mean age of ≥70 years. Am J Cardiol. 2013;112:615–22. doi: 10.1016/j.amjcard.2013.04.034.
    1. Authors/Task Force members. Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, et al. 2014 ESC/EACTS guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the Special Contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Eur Heart J. 2014;35:2541–619. doi: 10.1093/eurheartj/ehu278.
    1. He JQ, Gao YC, Yu XP, Zhang XL, Luo YW, Wu CY, et al. Syntax score predicts clinical outcome in patients with three-vessel coronary artery disease undergoing percutaneous coronary intervention. Chin Med J. 2011;124:704–9.
    1. Grapow MT, von Wattenwyl R, Guller U, Beyersdorf F, Zerkowski HR. Randomized controlled trials do not reflect reality: Real-world analyses are critical for treatment guidelines! J Thorac Cardiovasc Surg. 2006;132:5–7. doi: 10.1016/j.jtcvs.2006.03.035.
    1. Kunz R. Randomized trials and observational studies: Still mostly similar results, still crucial differences. J Clin Epidemiol. 2008;61:207–8. doi: 10.1016/j.jclinepi.2007.05.021.
    1. Guller U. Surgical outcomes research based on administrative data: inferior or complementary to prospective randomized clinical trials. World J Surg. 2006;30:255–66. doi: 10.1007/s00268-005-0156-0.
    1. Hoffman SN, TenBrook JA, Wolf MP, Pauker SG, Salem DN, Wong JB. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes. J Am Coll Cardiol. 2003;41:1293–304. doi: S0735109703001578.
    1. Brener SJ, Lytle BW, Casserly IP, Schneider JP, Topol EJ, Lauer MS. Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features. Circulation. 2004;109:2290–5. doi: 10.1161/01.CIR.0000126826.58526.14.

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