Five-year follow-up of patients treated for coronary artery disease in the face of an increasing burden of co-morbidity and disease complexity (from the NHLBI Dynamic Registry)

Abstract

Management of coronary artery disease (CAD) has evolved over the past decade, but there are few prospective studies evaluating long-term outcomes in a real-world setting of evolving technical approaches and secondary prevention. The aim of this study was to determine how the mortality and morbidity of CAD has changed in patients who have undergone percutaneous coronary intervention (PCI), in the setting of co-morbidities and evolving management. The National Heart, Lung, and Blood Institute Dynamic Registry was a cohort study of patients undergoing PCI at various time points. Cohorts were enrolled in 1999 (cohort 2, n = 2,105), 2004 (cohort 4, n = 2,112), and 2006 (cohort 5, n = 2,176), and each was followed out to 5 years. Primary outcomes were death, myocardial infarction (MI), coronary artery bypass grafting, repeat PCI, and repeat revascularization. Secondary outcomes were PCI for new obstructive lesions at 5 years, 5-year rates of death and MI stratified by the severity of coronary artery and co-morbid disease. Over time, patients were more likely to have multiple co-morbidities and more severe CAD. Despite greater disease severity, there was no significant difference in death (16.5% vs 17.6%, adjusted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.74 to 1.08), MI (11.0% vs 10.6%, adjusted HR 0.87, 95% CI 0.70 to 1.08), or repeat PCI (20.4% vs 22.2%, adjusted HR 0.98, 95% CI 0.85 to 1.17) at 5-year follow-up, but there was a significant decrease in coronary artery bypass grafting (9.1% vs 4.3%, adjusted HR 0.44, 95% CI 0.32 to 0.59). Patients with 5 co-morbidities had a 40% to 60% death rate at 5 years. There was a modestly high rate of repeat PCI for new lesions, indicating a potential failure of secondary prevention for this population in the face of increasing co-morbidity. Overall 5-year rates of death, MI, repeat PCI, and repeat PCI for new lesions did not change significantly in the context of increased co-morbidities and complex disease.

Fig. 1

a) Prevalence in the number of co-morbid conditions by recruitment cohort. Co-morbidities were defined as: smoking, diabetes, renal insufficiency, peripheral arterial disease, hypertension, and/or hypercholesterolemia. b)Prevalence in the number of severe coronary artery disease characteristics by recruitment cohort. Severe coronary artery disease was defined as: calcified stenoses, total occlusions, left main lesions ≥ 50%, type C lesions and/or triple vessel disease.

Fig. 1

a) Prevalence in the number of co-morbid conditions by recruitment cohort. Co-morbidities were defined as: smoking, diabetes, renal insufficiency, peripheral arterial disease, hypertension, and/or hypercholesterolemia. b)Prevalence in the number of severe coronary artery disease characteristics by recruitment cohort. Severe coronary artery disease was defined as: calcified stenoses, total occlusions, left main lesions ≥ 50%, type C lesions and/or triple vessel disease.

Fig. 2. Five-year unadjusted rates of a) death, b) myocardial infarction (MI), c) coronary artery bypass grafting (CABG), and d) repeat percutaneous coronary intervention (PCI)

Fig. 2d showsin-stent restenosis and repeat PCI to additional segments within the same coronary artery/graft stented at the time of enrollment into the Dynamic Registry.

Fig 3. Repeat percutaneous coronary intervention (PCI) for de novo lesions

Repeat PCI for new obstructive lesions outside of the segment stented at the time of enrollment in either the same vessel or other vessels, by recruitment cohort.

Fig 4. Cumulative five-year incidence of a) death, b) myocardial infarction (MI), and c) percutaneous coronary intervention (PCI) of de novo lesions by number of co-morbidities and recruitment cohort

The number of co-morbidities was defined as any combination of one or more of the following; smoking, diabetes mellitus type II, renal insufficiency, peripheral arterial disease, hypertension, and/or hypercholesterolemia.