Effectiveness of Clinical, Surgical and Percutaneous Treatment to Prevent Cardiovascular Events in Patients Referred for Elective Coronary Angiography: An Observational Study

Abstract

Purpose: To ascertain the most appropriate treatment for chronic, stable, coronary artery disease (CAD) in patients submitted to elective coronary angiography.

Patients and methods: A total of 814 patients included in the prospective cohort study were referred for elective coronary angiography and were followed up on average for 6±1.9 years. Main outcomes were all-cause death, cardiovascular death, non-fatal myocardial infarction (MI) and stroke and late revascularization and their combinations as major adverse cardiac and cerebral events (MACCE): MACCE-1 included cardiovascular death, nonfatal MI, and stroke; MACCE-2 was MACCE-1 plus late revascularization. Survival curves and adjusted Cox proportional hazard models were used to explore the association between the type of treatment and outcomes.

Results: All-cause death was lower in participants submitted to percutaneous coronary intervention (PCI) (0.41, 0.16-1.03, P=0.057) compared to medical treatment (MT). Coronary-artery bypass grafting (CABG) had an overall trend for poorer outcomes: cardiovascular death 2.53 (0.42-15.10), combined cardiovascular death, nonfatal MI, and stroke 2.15 (0.73-6.31) and these events plus late revascularization (2.17, 0.86-5.49). The corresponding numbers for PCI were 0.27 (0.05-1.43) for cardiovascular death, 0.77 (0.32-1.84) for combined cardiovascular death, nonfatal MI, and stroke and 2.35 (1.16-4.77) with the addition of late revascularization. These trends were not influenced by baseline blood pressure, left ventricular ejection fraction and previous MI. Patients with diabetes mellitus had a significantly higher risk of recurrent revascularization when submitted to PCI than CABG.

Conclusion: Patients with confirmed CAD in elective coronary angiography do not have a better prognosis when submitted to CABG comparatively to medical treatment. Patients treated with PCI had a trend for the lower incidence of combined cardiovascular events, at the expense of additional revascularization procedures. Patients without significant CAD had a similar prognosis than CAD patients treated with medical therapy.

Keywords: SYNTAX score; coronary artery bypass grafting; myocardial revascularization; percutaneous coronary intervention; stable coronary artery disease.

Figure 1

Study flowchart. PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; CAD, coronary artery disease; MACCE, major adverse cardiac and cerebral events, as defined in Methods section.

Figure 2

Event-free survival curves for all-cause death, cardiovascular death, MACCE-1, and MACCE-2 adjusted for age, sex, school degree, BMI, DM, hypertension, chest pain, HDL-C, creatinine, hs-CRP, smoking, HF, LVEF, MI before the index procedure and SXscore. CABG, coronary-artery bypass grafting; MT, medical-therapy; PCI, percutaneous coronary intervention. Abbreviations as in Table 1.

Figure 3

Hazard ratio for MACCE-2 in participants stratified by diabetes mellitus, myocardial infarction, categories of systolic blood pressure, and left ventricular ejection fraction. *Adjusted for model 3 as. Table 3. **Normal for male ≥ 52% and for female ≥ 54%. Abbreviations as in Table 1.