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Modifiable Risk Factors and Residual Risk Following Coronary Revascularization: Insights From a Regionalized
Trevor Simard1,2,3, Richard G Jung1,2, Pietro Di Santo1
1CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Insights
Patients undergoing revascularization face ongoing risks for major adverse cardiovascular events (MACE). Many patients have uncontrolled risk factors like diabetes and smoking post-procedure, emphasizing the need for improved secondary prevention strategies.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Preventive Cardiology
Background:
- Coronary revascularization reduces ischemia but requires ongoing risk management for coronary artery disease (CAD).
- Post-revascularization care is often less structured than pre-procedural pathways.
- Optimizing secondary prevention is crucial for long-term patient outcomes.
Purpose of the Study:
- To assess compliance with secondary prevention guidelines after revascularization.
- To document residual cardiovascular risk in patients 1 year post-procedure.
- To evaluate the effectiveness of a dedicated postrevascularization clinic.
Main Methods:
- Prospective data collection from 4147 patients in the CAPITAL revascularization registry (2015-2019).
- Analysis of procedural, clinical, and outcome data at 1-year follow-up.
- Definition of Major Adverse Cardiovascular Event (MACE) including death, myocardial infarction, unplanned revascularization, or stroke.
Main Results:
- 11% of patients experienced MACE within 1 year post-revascularization; female patients were disproportionately affected.
- 47.7% of patients had multiple uncontrolled risk factors (diabetes, dyslipidemia, overweight, smoking).
- High rates of suboptimal risk factor control: 45% of diabetics with uncontrolled HbA1c, 54.8% of smokers continued smoking, and 27.1% had unachieved lipid targets.
Conclusions:
- Patients remain at significant risk for MACE after revascularization due to prevalent, inadequately controlled risk factors.
- There is a clear need for intensified secondary prevention strategies.
- Implementing structured programs to optimize post-revascularization care is essential.
Objective:
To ensure compliance with optimal secondary prevention strategies and document the residual risk of patients following revascularization, we established a postrevascularization clinic for risk-factor optimization at 1 year, with outcomes recorded in a web-based registry. Although coronary revascularization can reduce ischemia, medical treatment of coronary artery disease (CAD) remains the cornerstone of ongoing risk reduction. While standardized referral pathways and protocols for revascularization are prevalent and well studied, post-revascularization care is often less formalized.
Patients And Methods:
The University of Ottawa Heart Institute is a tertiary-care center providing coronary revascularization services. From 2015 to 2019, data were prospectively recorded in the CAPITAL revascularization registry, and patient-level procedural, clinical, and outcome data are collected in the year following revascularization. Major adverse cardiovascular event (MACE) was defined as death, myocardial infarction, unplanned revascularization, or cerebrovascular accident. Kaplan-Meier curves were generated to evaluate time-to-event data for clinical outcomes by risk-factor management, and comparisons were performed using log-rank tests and reported by hazard ratio (HR) and 95% confidence intervals (CIs).
Results:
A cohort of 4147 patients completed 1-year follow-up after revascularization procedure that included 3462 undergoing percutaneous coronary intervention (PCI), 589 undergoing coronary artery bypass graft (CABG), and 96 undergoing both PCI and CABG. In the year following revascularization (median follow-up 13.3 months-interquartile range [IQR]: 11.9-16.5) 11% of patients experienced MACE, with female patients being disproportionately at risk. Moreover, 47.7% of patients had ≥2 risk factors (diabetes, dyslipidemia, overweight, active smoker) at the time of follow-up, with 45.0% of patients with diabetes failing to achieve target hemoglobin (Hb) A1c, 54.8% of smokers continuing to smoke, and 27.1% of patients failing to achieve guideline-directed lipid targets.
Conclusion:
Patients who have undergone revascularization procedures remain at elevated risk for MACE, and inadequately controlled risk factors are prevalent in follow-up. This highlights the need for aggressive secondary prevention strategies and implementation of programs to optimize postrevascularization care.
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