Outcomes of different revascularization strategies among patients presenting with acute coronary syndromes without ST
Eilon Ram1, Leonid Sternik1, Robert Klempfner2
1Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel.
Insights
Coronary artery bypass grafting (CABG) shows better long-term survival than percutaneous coronary intervention (PCI) for non-ST-segment myocardial infarction (NSTEMI) or unstable angina (UA). This benefit was observed exclusively in male patients, highlighting sex-specific outcomes in cardiac revascularization.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Non-ST-segment myocardial infarction (NSTEMI) and unstable angina (UA) are acute coronary syndromes requiring revascularization.
- Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are primary revascularization strategies.
- Real-world data comparing long-term outcomes of CABG versus PCI in NSTEMI/UA patients is crucial.
Purpose of the Study:
- To compare short- and long-term outcomes of NSTEMI/UA patients treated with CABG versus PCI.
- To identify predictors for CABG referral in a real-world setting.
- To analyze sex-specific differences in outcomes following revascularization.
Main Methods:
- Observational study of 5112 NSTEMI/UA patients from the Acute Coronary Syndrome Israeli Survey (2000-2016).
- Propensity score-matching analysis (1:1) comparing early outcomes and all-cause mortality between CABG and PCI groups.
- Multivariable analysis to identify independent predictors of mortality and referral patterns.
Main Results:
- CABG referral was associated with 3-vessel coronary artery disease (CAD), absence of on-site cardiac surgery, no prior PCI, and no prior myocardial infarction.
- The 10-year mortality risk was significantly lower for CABG (20.4%) compared to PCI (28.4%) (P=0.006).
- CABG referral independently reduced 10-year mortality risk by 65% (P < 0.001), an advantage observed only in male patients.
Conclusions:
- CABG offers superior long-term outcomes compared to PCI in patients with NSTEMI or UA in a real-world setting.
- The survival benefit of CABG over PCI is sex-specific, predominantly benefiting male patients.
- These findings emphasize the importance of considering patient sex in revascularization strategy selection.
Objective:
To compare short- and long-term outcomes of patients hospitalized with non-ST-segment myocardial infarction (NSTEMI) or unstable angina (UA) who were referred for revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in a real-world national cohort.
Methods:
This observational study included 5112 patients, who underwent either CABG or PCI, admitted for NSTEMI or UA and were enrolled in the Acute Coronary Syndrome Israeli Survey between 2000 and 2016. Propensity score-matching analysis compared early outcomes and all-cause mortality in patients who underwent revascularization by PCI with revascularization by CABG.
Results:
Of the 5112 patients, 4327 (85%) underwent PCI and 785 (15%) CABG. Following propensity score analysis, 447 pairs were chosen (1:1). Independent predictors for CABG referral included 3-vessel CAD (odds ratio [OR], 5.5; 95% confidence interval [CI], 4.5-6.7, P < .001), absence of on-site cardiac surgery (OR, 1.3; 95% CI, 1.1-1.6, P = .004), no previous PCI (OR, 1.5; 95% CI, 1.2-1.9, P = .002) and no previous myocardial infarction (OR, 1.3; 95% CI, 1-1.7, P = .022). The 10-year mortality risk was significantly lower among those who underwent CABG compared with PCI (20.4% vs 28.4%, P = .006). Consistent with these findings, multivariable analysis showed that referral to CABG was independently associated with a significant 65% reduction in the risk of 10-year mortality (P < .001). This long-term advantage was seen among male patients (P < .001) and not female patients (P = .910).
Conclusions:
In a real-life setting, revascularization by CABG provides excellent long-term outcomes in patients with NSTEMI or UA. The advantage of CABG over PCI was seen only in male patients.
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