Determinants of excess mortality following unprotected left main stem percutaneous coronary intervention
O A Alabas1, R A Brogan2, M Hall1
1MRC Bioinformatics Unit, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK.
Insights
Long-term survival after unprotected left main stem PCI varies by patient condition. Survival is high for stable angina but poor for STEMI with cardiogenic shock, influenced by factors like renal failure and ventilation needs.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Health Outcomes Research
Background:
- Limited long-term outcome data exist for unprotected left main stem percutaneous coronary intervention (UPLMS PCI).
- Assessing 5-year survival requires accounting for background population mortality.
Purpose of the Study:
- To evaluate the 5-year survival rates for patients undergoing UPLMS PCI.
- To identify predictors of excess mortality in different patient subgroups.
Main Methods:
- A population-based registry of 10,682 UPLMS PCI cases (2005-2014) was analyzed.
- Cases were matched to UK death data for 56.6 million people.
- Relative survival and excess mortality were estimated.
Main Results:
- Crude 5-year survival: 93.8% (CSA), 73.1% (NSTEACS), 77.5% (STEMI-CS), 28.5% (STEMI+CS).
- Predictors of excess mortality included renal failure (CSA), preprocedural ventilation (NSTEACS, STEMI-CS), and TIMI 0 flow (STEMI+CS).
- Multivessel PCI was associated with improved survival.
Conclusions:
- Long-term survival for UPLMS PCI in chronic stable angina is high and influenced by comorbidities.
- Preprocedural ventilation is a key determinant of excess mortality in NSTEACS and STEMI-CS.
- For STEMI+CS, preprocedural TIMI flow is the strongest mortality predictor; non-cardiovascular deaths should be considered in future studies.
Objective:
For percutaneous coronary intervention (PCI) to the unprotected left main stem (UPLMS), there are limited long-term outcome data. We evaluated 5-year survival for UPLMS PCI cases taking into account background population mortality.
Methods:
A population-based registry of 10 682 cases of chronic stable angina (CSA), non-ST-segment elevation acute coronary syndrome (NSTEACS), ST-segment elevation myocardial infarction with (STEMI+CS) and without cardiogenic shock (STEMI-CS) who received UPLMS PCI from 2005 to 2014 were matched by age, sex, year of procedure and country to death data for the UK populace of 56.6 million people. Relative survival and excess mortality were estimated.
Results:
Over 26 105 person-years follow-up, crude 5-year relative survival was 93.8% for CSA, 73.1% for NSTEACS, 77.5% for STEMI-CS and 28.5% for STEMI+CS. The strongest predictor of excess mortality among CSA was renal failure (EMRR 6.73, 95% CI 4.06 to 11.15), and for NSTEACS and STEMI-CS was preprocedural ventilation (6.25, 5.05 to 7.75 and 6.92, 4.25 to 11.26, respectively). For STEMI+CS, the strongest predictor of excess mortality was preprocedural thrombolysis in myocardial infarction (TIMI) 0 flow (2.78, 1.87 to 4.13), whereas multivessel PCI was associated with improved survival (0.74, 0.61 to 0.90).
Conclusions:
Long-term survival following UPLMS PCI for CSA was high, approached that of the background populace and was significantly predicted by co-morbidity. For NSTEACS and STEMI-CS, the requirement for preprocedural ventilation was the strongest determinant of excess mortality. By contrast, among STEMI+CS, in whom survival was poor, the strongest determinant was preprocedural TIMI flow. Future cardiovascular cohort studies of long-term mortality should consider the impact of non-cardiovascular deaths.
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