login
  Password reminder
Cardiovascular News
Contact the editor Visit Cardiovascular News Twitter feed Visit Cardiovascular News Facebook page
 

Clinical vs. anatomical risk stratification following complex PCI


Friday, 05 Aug 2011 10:27
Ralf Lehmann
Ralf Lehmann


By Ralf Lehmann


Surgical or interventional coronary revascularisation is the primary therapeutic choice in coronary artery disease patients with multivessel disease or with involvement of the left main coronary artery (LMCA). The decision between revascularisation by percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in multivessel disease patients is often made by estimating the perioperative mortality for CABG using logistic regression-based clinical risk scores such as the EuroSCORE. However, the EuroSCORE is not validated regarding long-term outcome after CABG. The SYNTAX Score represents an anatomical risk stratification score for coronary artery disease patients and has recently been proposed to predict clinical outcome after multivessel PCI. However, the prognostic impact of different clinical and anatomical risk stratification scores for the long-term survival after multivessel PCI has not yet been investigated and compared sufficient. Finally, current guidelines on choosing a revascularisation strategy only focus on anatomical features rather than on clinical parameters.

 

In order to investigate these questions we conducted a single-centre registry with “all-comers” patients. Our study population consisted of 740 consecutive patients undergoing coronary stent implantation in at least two main vessel territories (LAD, RCA, RCX, RIM, LMCA=counted as two territories) in a single session at the University Hospital of Frankfurt, Germany. Clinical long-term follow-up regarding survival was available in a total of 726 (98%) patients with a mean follow-up of 5.3±2.1 years (patients alive).

 

Nearly half of the patients received multivessel PCI in the setting of an acute coronary syndrome (n=150 NSTEMI; n=191 STEMI). The mean age was 65±11 years, 77% were male, and 29% of the patients were diabetic. By definition the EuroSCORE was markedly lower for stable patients in comparison to patients with an acute coronary syndrome (stable 4.1±4.5, NSTEMI 13.9±13.3, STEMI 18.1±18.7, p <0.001). However, for the SYNTAX Score this difference was much less pronounced but still significant (stable coronary artery disease 14.9±8.6; NSTEMI 17.8±9.9; STEMI 18.3±9.0: p <0.001).

The patient population was divided into tertiles for each of the calculated scores.

 

Subsequently Kaplan-Meier survival estimates were performed to compare the different risk levels. Patients in the higher EuroSCORE tertile experienced a dramatically elevated mortality risk across the entire study period when compared with the lower two tertiles. The elevated mortality rate in the highest tertiles of the clinical scores was attributed in part to the high short-term mortality of patients with acute myocardial infarction and especially cardiogenic shock. This led us to perform a separate analysis for stable patients only, in which the discrimination of the long-term survival by tertiles of EuroSCORE was even more pronounced, as reflected by the diverging Kaplan-Meier curves. These results indicate that the discriminating potential of the clinical scores is not only powered by short term “acute” clinical parameters. Finally, the SYNTAX Score predicts long-term survival worse than EuroSCORE, as shown by a smaller difference between the highest and lowest tertiles. In the stable patient population, the SYNTAX Score lost its predictive ability completely.

 

The outstanding role of the EuroSCORE was confirmed by a multivariable Cox regression analysis adjusted for the relevant baseline characteristics. The EuroSCORE remained as independent predictors of long-term mortality in the entire population (HR per tertile 2.03; 95% CI 1.53–2.69).

 

In conclusion, a combination of clinical and anatomical risk factors may provide the optimal predictive model in patients undergoing multivessel PCI. Furthermore, the ideal combination of clinical and anatomic risk stratification should be conclusive for patients undergoing CABG as well.

 

Ralf Lehmann is an interventional cardiologist at Klinikum der JW Goethe Universität, Frankfurt, Germany.  





Add New Comment

Related Items


Most popular


Drug-coated balloons are not inferior to drug-eluting stents for treating stent restenosis
Friday, 06 Mar 2015
A retrospective study indicates that drug-coated balloons are associated with similar angiographic and clinical outcomes to drug-eluting stents (including both first- and second-generation stents) ... Drug-coated balloons are not inferior to drug-eluting stents for treating stent restenosis

Thursday, 26 Feb 2015
Vitaria delivers autonomic regulation therapy for patients who have moderate to severe heart failure with left ventricular dysfunction (ejection fraction < 40%), and who remain symptomatic despite ... Vitaria vagal nerve stimulation system receives CE mark for treatment of chronic heart failure

Boston Scientific receives FDA approval for Watchman left atrial appendage closure device
Monday, 16 Mar 2015
The device offers an alternative to long-term warfarin therapy for stroke risk reduction in patients with non-valvular atrial fibrillation. Boston Scientific receives FDA approval for Watchman left atrial appendage closure device

Features


Robotic PCI could be used to reduce radiation exposure to the operator
Thursday, 09 Apr 2015
Ryan Madder, an interventional cardiologist at the Frederik Meijer Heart & Vascular Institute (Spectrum Health, Grand Rapids, Michigan, USA) explains why he believes a robotic system (CorPath, C... Robotic PCI could be used to reduce radiation exposure to the operator

SERVE-HF could be a wake-up call for cardiologists about central sleep apnoea
Tuesday, 24 Mar 2015
Martin Cowie (Imperial College London, London, UK) is the principal investigator of the SERVE-HF study, which is assessing the use of adaptive servo-ventilation (PaceWave, ResMed) in chronic heart ... SERVE-HF could be a wake-up call for cardiologists about central sleep apnoea

Profiles


Flavio Ribichini
Thursday, 05 Mar 2015
Flavio Ribichini speaks to Cardiovascular News about being involved in the first use of primary ... Flavio Ribichini

Sunil Rao
Thursday, 23 Oct 2014
Sunil Rao speaks to Cardiovascular News about his career highlights, including his research into ... Sunil Rao

Cardiac Rhythm News Vascular News Cardiovascular News Interventional News Spinal News NeuroNews
BIBA Medical BIBA MedTech Insights CX Symposium ilegx
 
Password Reminder

BIBA Medical, 526 Fulham Road, Fulham, London, SW6 5NR.
TEL: +44 (0)20 7736 8788 FAX: +44 (0)20 7736 8283 EMAIL: 
info@bibamedical.com
© BIBA Medical Ltd is a company registered in England and Wales with company number 2944429.
VAT registration number 730 6811 50.
Site Map | Terms and Conditions