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Prognostic impact of patients' management based on anatomic/functional phenotype: a study in patients with chronic
Riccardo Liga1,2, Danilo Neglia3,4, Samuele Cavaleri3
1Dipartimento Cardio-Toracico e Vascolare, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
Insights
Appropriate management of stable coronary artery disease (CAD) based on patient anatomy and ischemia significantly improves long-term prognosis. Inappropriate treatment, whether undertreatment or overtreatment, is linked to worse cardiac outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Nuclear Cardiology
Background:
- Stable coronary artery disease (CAD) management requires evaluating clinical factors alongside treatment appropriateness.
- Anatomic and functional phenotypes are crucial for guiding optimal patient care.
Purpose of the Study:
- To assess the prognostic impact of treatment appropriateness in stable CAD patients.
- To correlate management strategies with long-term clinical outcomes based on coronary anatomy and myocardial ischemia.
Main Methods:
- 1585 patients with stable CAD underwent myocardial perfusion scintigraphy and coronary angiography.
- Treatment appropriateness was defined by revascularizing hemodynamically significant lesions or opting for medical therapy in their absence.
- Patient outcomes were tracked for a mean of 4.7 years.
Main Results:
- 75% of patients had obstructive CAD, and 29% had moderate-to-severe ischemia.
- Inappropriate management occurred in 389 patients (undertreatment or overtreatment).
- Inappropriate management was independently associated with adverse cardiac events (primary endpoint).
Conclusions:
- Management guided by anatomic and functional phenotyping in stable CAD offers a prognostic advantage.
- Incomplete revascularization or undertreatment of significant CAD increased adverse events compared to complete revascularization.
- Revascularizing non-significant CAD lesions was associated with higher event rates than medical management.
Background:
In stable coronary artery disease (CAD), the prognostic interaction between clinical variables and treatment appropriateness based on anatomic/functional phenotype needs to be evaluated.
Methods:
1585 consecutive patients underwent myocardial perfusion scintigraphy and coronary angiography within 90 days. Obstructive CAD (> 70% stenosis) with downstream moderate-to-severe ischemia (> 10%) was considered significant. Coronary revascularization was considered appropriate if all hemodynamically significant lesions were revascularized, while medical therapy only was deemed appropriate in the absence of hemodynamically significant CAD.
Results:
Obstructive CAD and moderate-to-severe ischemia were documented in 1184 (75%) and 466 (29%) patients, respectively. Over mean follow-up of 4.7 ± 2.5 years, the primary endpoint (cardiac death and non-fatal myocardial infarction) occurred in 132 (8.2%) patients. Of patients with obstructive CAD, 797 (67%) were managed appropriately. Patients' management was inappropriate in 389 patients, because either non-hemodynamically significant lesions were revascularized (50%, including 2 patients with non-obstructive lesions being inappropriately revascularized) or ischemia-causing CAD was left untreated (50%). At multivariate analysis, an inappropriate management (P < .001) was correlated with the primary endpoint, together with previous myocardial infarction (P = .009), lower ejection fraction (P < .001) and higher glucose levels (P < .001).
Conclusions:
In stable CAD patients, management based on anatomic/functional phenotyping was correlated with a prognostic advantage at long-term follow-up. Correlation between treatment categories and patients' prognosis. A significantly higher event-rate was observed in patients where hemodynamically significant coronary lesions were left untreated-either because MT was not-adherently chosen or in the case of incomplete revascularization-than in those that were revascularized completely (17.6% vs 5.1%; P < .001). Conversely, the revascularization of non-hemodynamically significant CAD correlated with a higher event-rate than that of similar patients managed medically (13.8% vs 8.3%, P = .04). The event-rate of patients in whom coronary revascularization was performed in the presence of hemodynamically significant CAD ('appropriate revascularization') was similar to those with "No CAD/non-obstructive CAD" (5.1% vs 3.5%; P = NS).
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