Impact of Complete Revascularization on Development of Heart Failure in Patients With Acute Coronary Syndrome and Multivessel Disease: A Subanalysis of the CORALYS Registry

Abstract

Background The impact of complete revascularization (CR) on the development of heart failure (HF) in patients with acute coronary syndrome and multivessel coronary artery disease undergoing percutaneous coronary intervention remains to be elucidated. Methods and Results Consecutive patients with acute coronary syndrome with multivessel coronary artery disease from the CORALYS (Incidence and Predictors of Heart Failure After Acute Coronary Syndrome) registry were included. Incidence of first hospitalization for HF or cardiovascular death was the primary end point. Patients were stratified according to completeness of coronary revascularization. Of 14 699 patients in the CORALYS registry, 5054 presented with multivessel disease. One thousand four hundred seventy-three (29.2%) underwent CR, while 3581 (70.8%) did not. Over 5 years follow-up, CR was associated with a reduced incidence of the primary end point (adjusted hazard ratio [HR], 0.66 [95% CI, 0.51-0.85]), first HF hospitalization (adjusted HR, 0.67 [95% CI, 0.49-0.90]) along with all-cause death and cardiovascular death alone (adjusted HR, 0.74 [95% CI, 0.56-0.97] and HR, 0.56 [95% CI, 0.38-0.84], respectively). The results were consistent in the propensity-score matching population and in inverse probability treatment weighting analysis. The benefit of CR was consistent across acute coronary syndrome presentations (HR, 0.59 [95% CI, 0.39-0.89] for ST-segment elevation myocardial infarction and HR, 0.71 [95% CI, 0.50-0.99] for non-ST-elevation acute coronary syndrome) and in patients with left ventricular ejection fraction >40% (HR, 0.52 [95% CI, 0.37-0.72]), while no benefit was observed in patients with left ventricular ejection fraction ≤40% (HR, 0.77 [95% CI, 0.37-1.10], P for interaction 0.04). Conclusions CR after acute coronary syndrome reduced the risk of first hospitalization for HF and cardiovascular death, as well as first HF hospitalization, and cardiovascular and overall death both in patients with ST-segment elevation myocardial infarction and non-ST-elevation acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04895176.

Keywords: acute coronary syndrome; complete revascularization; heart failure; multivessel disease; myocardial infarction; percutaneous coronary intervention.

Figure 1. Unadjusted Kaplan−Meier incidence of primary end point (left) and first HF hospitalization (right).

CR indicates complete revascularization; CV, cardiovascular; HF, heart failure; HR, hazard ratio; and ICR, incomplete revascularization.

Figure 2. Study summary. Kaplan−Meier incidence of primary end point (left) and first HF hospitalization (right) in the propensity‐matched population.

ACS indicates acute coronary syndrome; CORALYS, Incidence and Predictors of Heart Failure After Acute Coronary Syndrome; CR, complete revascularization; CV, cardiovascular; HF, heart failure; HR, hazard ratio; ICR, incomplete revascularization; and PSM, propensity‐score matched.

Figure 3. Kaplan−Meier incidence of all‐cause death (left) and cardiovascular death (right) in the propensity‐matched population.

CR indicates complete revascularization; HR, hazard ratio; ICR, incomplete revascularization; and PSM, propensity‐score matched.

Figure 4. Kaplan−Meier incidence of primary end point and first HF hospitalization according to ACS presentation in the whole population (upper part) and in the propensity‐matched population (lower part).

ACS indicates acute coronary syndrome; CR, complete revascularization; CV, cardiovascular; HF, heart failure; HR, hazard ratio; ICR, incomplete revascularization; NSTE, non‐ST‐elevation; PSM, propensity‐score matched; and STEMI, ST‐elevation myocardial infarction.

Figure 5. Unadjusted Kaplan−Meier incidence of primary end point according to LVEF.

CR indicates complete revascularization; CV, cardiovascular; HF, heart failure; ICR, incomplete revascularization; and LVEF, left ventricular ejection fraction.

Figure 6. Subgroup analysis on the impact of CR on primary end point.

ACS indicates acute coronary syndrome; AF, atrial fibrillation; BMS, bare metal stent; CABG, coronary artery bypass graft; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CR, complete revascularization; DES, drug‐eluting stent; EF, ejection fraction; GRACE, Global Registry of Acute Coronary Events; HR, hazard ratio; ICR, incomplete revascularization; MI, myocardial infarction; NSTE, non‐ST‐elevation; PAD, peripheral artery disease; PCI, percutaneous coronary intervention; STEMI, ST‐elevation myocardial infarction; and ULM, unprotected left main.