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Published on: January 28, 2020
Incidence and Prognostic Impact of Incomplete Revascularization Documented by Coronary Angiography 1 Year After
Brack Hattler1, Frederick L Grover2, Todd Wagner3
1Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO; Department of Medicine, University of Colorado School of Medicine, Aurora, CO.
Insights
Complete revascularization (CR) after coronary artery bypass graft (CABG) surgery significantly reduces major adverse cardiovascular events (MACE). Angiography confirmed CR improved outcomes, but did not impact mortality rates over four years.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Complete revascularization (CR) during coronary artery bypass graft (CABG) surgery is linked to better long-term cardiac outcomes.
- Previous studies lacked angiographic confirmation of CR rates post-CABG.
Purpose of the Study:
- To evaluate the long-term effects of angiographically confirmed CR versus incomplete revascularization (IR) after CABG.
- To assess the impact on mortality and major adverse cardiovascular events (MACE).
Main Methods:
- Analysis of patients from the Randomized On/Off Bypass Study who underwent 1-year post-CABG angiography.
- CR defined as a patent graft to each major diseased coronary artery territory.
- Outcomes measured: all-cause mortality and MACE over 4 years post-angiography.
Main Results:
- Of 1,276 patients, 59% achieved CR and 41% had IR.
- MACE occurred in 13% of CR patients versus 26% of IR patients (p <0.001).
- Repeat revascularization was the primary driver of MACE difference (5% CR vs. 18% IR; p <0.001). No significant difference in mortality or myocardial infarction.
Conclusions:
- Angiographically confirmed CR after CABG is associated with reduced MACE, primarily due to fewer repeat revascularizations.
- CR did not demonstrate a significant impact on long-term mortality in this cohort.
- Potential mortality benefits in the IR group may have been influenced by subsequent interventions based on research angiography findings.
Abstract:
Complete revascularization (CR) at the time of coronary artery bypass graft (CABG) surgery improves long-term cardiac outcomes. No studies have previously reported angiographically confirmed CR rates post-CABG. This study's aim was to assess the impact upon long-term outcomes of CR versus incomplete revascularization (IR), confirmed by coronary angiography 1 year after CABG. Randomized On/Off Bypass Study patients who returned for protocol-specified 1-year post-CABG coronary angiograms were included. Patients with a widely patent graft supplying the major diseased artery within each diseased coronary territory were considered to have CR. Outcomes were all-cause mortality and major adverse cardiovascular events (MACE; all-cause mortality, nonfatal myocardial infarction, repeat revascularization) over the 4 years after angiography. Of the 1,276 patients, 756 (59%) had CR and 520 (41%) had IR. MACE was 13% CR versus 26% IR, p <0.001. This difference was driven by fewer repeat revascularizations (5% CR vs 18% IR; p <0.001). There were no differences in mortality (7.1% CR vs 8.1% IR, p = 0.13) or myocardial infarction (4% in both). Adjusted multivariable models confirmed CR was associated with reduced MACE (odds ratio 0.44, 95% confidence interval 0.33 to 0.58, p <0.01), but had no impact on mortality. In conclusion, CR confirmed by post-CABG angiography was associated with improved MACE but not mortality. Repeat revascularization of patients with IR, driven by knowledge of the research angiography results, may have ameliorated potential mortality differences.
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