Impact of established cardiovascular disease on 10-year death after coronary revascularization for complex coronary artery disease

Rutao Wang, Scot Garg, Chao Gao, Hideyuki Kawashima, Masafumi Ono, Hironori Hara, Robert-Jan van Geuns, Marie-Claude Morice, Piroze M Davierwala, Arie Pieter Kappetein, David R Holmes, William Wijns, Ling Tao, Yoshinobu Onuma, Patrick W Serruys, Rutao Wang, Scot Garg, Chao Gao, Hideyuki Kawashima, Masafumi Ono, Hironori Hara, Robert-Jan van Geuns, Marie-Claude Morice, Piroze M Davierwala, Arie Pieter Kappetein, David R Holmes, William Wijns, Ling Tao, Yoshinobu Onuma, Patrick W Serruys

Abstract

Aims: To investigate the impact of established cardiovascular disease (CVD) on 10-year all-cause death following coronary revascularization in patients with complex coronary artery disease (CAD).

Methods: The SYNTAXES study assessed vital status out to 10 years of patients with complex CAD enrolled in the SYNTAX trial. The relative efficacy of PCI versus CABG in terms of 10-year all-cause death was assessed according to co-existing CVD.

Results: Established CVD status was recorded in 1771 (98.3%) patients, of whom 827 (46.7%) had established CVD. Compared to those without CVD, patients with CVD had a significantly higher risk of 10-year all-cause death (31.4% vs. 21.7%; adjusted HR: 1.40; 95% CI 1.08-1.80, p = 0.010). In patients with CVD, PCI had a non-significant numerically higher risk of 10-year all-cause death compared with CABG (35.9% vs. 27.2%; adjusted HR: 1.14; 95% CI 0.83-1.58, p = 0.412). The relative treatment effects of PCI versus CABG on 10-year all-cause death in patients with complex CAD were similar irrespective of the presence of CVD (p-interaction = 0.986). Only those patients with CVD in ≥ 2 territories had a higher risk of 10-year all-cause death (adjusted HR: 2.99, 95% CI 2.11-4.23, p < 0.001) compared to those without CVD.

Conclusions: The presence of CVD involving more than one territory was associated with a significantly increased risk of 10-year all-cause death, which was non-significantly higher in complex CAD patients treated with PCI compared with CABG. Acceptable long-term outcomes were observed, suggesting that patients with established CVD should not be precluded from undergoing invasive angiography or revascularization.

Trial registration: SYNTAX: ClinicalTrials.gov reference: NCT00114972. SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050.

Keywords: CABG; Cardiovascular disease; Left main coronary artery disease; PCI; Three-vessel disease.

Conflict of interest statement

Dr. Hara reports a grant for studying overseas from Japanese Circulation Society, a grant-in-Aid for JSPS Fellows and a grant from Fukuda Foundation for Medical Technology. Dr. van Geuns reports grants and personal fees from Boston Scientific, grants and personal fees from Abbott Vascular, grants and personal fees from Astra Zeneca, grants and personal fees from Amgen, grants from InfraRedx, outside the submitted work. Dr. Morice reports to work as the CEO of CERC, a CRO which was never involved in the SYNTAX trial at any level, except that submitted the 10-year additional follow-up (for free) to French authorities to get approval. Dr. Morice also reports to work as minor shareholder of electroducer. Dr. Kappetein reports to work as an employee of Medtronic, outside the submitted work. Dr. Wijns reports research grant and honoraria from MicroPort; medical advisor Rede Optimus Research and co-founder Argonauts, an innovation facilitator. Dr. Serruys reports personal fees from Biosensors, Micel Technologies, Sinomedical Sciences Technology, Philips/Volcano, Xeltis, and HeartFlow, outside the submitted work. All the other authors have no disclosures.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Ten-year all-cause death according to the extent of established CVD. a 10-year all-cause death in patients with established CVD versus those without; b 10-year all-cause death according to the extent of established CVD
Fig. 2
Fig. 2
Ten-year all-cause death according to revascularization strategies and established CVD. a patients with established CVD; b patients without established CVD
Fig. 3
Fig. 3
The individual difference between predicted mortality (dashed lines) using the SYNTAX Score II 2020 and the individual observed mortality (solid lines), between PCI and CABG in patients with established CVD. Blue dashed line represents the predicted mortality after PCI; red dashed line represents the predicted mortality after CABG; blue solid line represents the observed mortality after PCI; red solid line represents the observed mortality after CABG

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