Geographic disparity in 10-year mortality after coronary artery revascularization in the SYNTAXES trial
Shigetaka Kageyama1, Patrick W Serruys2, Scot Garg3
1Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.
Insights
This study on complex coronary artery disease (CAD) found lower 10-year mortality in Eastern, Northern, and Southern Europe compared to Western Europe after revascularization. Geographic disparities in outcomes exist following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).
Area of Science:
- Cardiology
- Global Health
- Clinical Trials
Background:
- Complex coronary artery disease (CAD) requires revascularization via percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).
- Geographic variations in healthcare access and patient characteristics may influence long-term outcomes.
- The SYNTAXES trial provides a unique dataset to explore these disparities.
Purpose of the Study:
- To investigate geographic disparities in long-term mortality following revascularization in patients with complex CAD.
- To compare 10-year survival rates across different recruitment regions in the SYNTAXES trial.
- To identify potential factors contributing to observed regional differences in mortality.
Main Methods:
- Analysis of the SYNTAXES trial data, randomizing 1800 patients with three-vessel and/or left main CAD to PCI or CABG.
- Stratification of patients based on recruitment region: North America, Eastern Europe, Northern Europe, Southern Europe, and Western Europe (reference).
- Assessment of 10-year survival, with adjustments for pre- and peri-procedural factors.
Main Results:
- Crude 10-year mortality was significantly lower in Eastern Europe (22.5%), Northern Europe (21.9%), and Southern Europe (22.0%) compared to Western Europe (30.7%).
- Adjusted mortality remained significantly lower in Northern Europe (HR 0.85) and Southern Europe (HR 0.72) compared to Western Europe.
- Patient demographics and baseline characteristics varied significantly across regions, including age, sex, diabetes, peripheral vascular disease, ejection fraction, and anatomic SYNTAX score.
Conclusions:
- Significant geographic disparities in 10-year mortality following revascularization for complex CAD exist.
- Lower mortality rates in Eastern, Northern, and Southern Europe suggest potential regional advantages or differing patient populations.
- Understanding these geographic variations is crucial for interpreting global clinical trial data and optimizing patient care worldwide.
Aims:
To investigate geographic disparity in long-term mortality following revascularization in patients with complex coronary artery disease (CAD).
Methods And Results:
The SYNTAXES trial randomized 1800 patients with three-vessel and/or left main CAD to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) and assessed their survival at 10 years. Patients were stratified according to the region of recruitment: North America (N-A, n = 245), Eastern Europe (E-E, n = 189), Northern Europe (N-E, n = 425), Southern Europe (S-E, n = 263), and Western Europe (W-E, n = 678), which also served as the reference group. Compared to W-E, patients were younger in E-E (62 vs 65 years, p < 0.001), and less frequently male in N-A (65.3% vs 79.6%, p < 0.001). Diabetes (16.0% vs 25.4%, p < 0.001) and peripheral vascular disease (6.8% vs 10.9%, p = 0.025) were less frequent in N-E than W-E. Ejection fraction was highest in W-E (62% vs 56%, p < 0.001). Compared to W-E, the mean anatomic SYNTAX score was higher in S-E (29 vs 31, p = 0.008) and lower in N-A (26, p < 0.001). Crude ten-year mortality was similar in N-A (31.6%), and W-E (30.7%), and significantly lower in E-E (22.5%, p = 0.041), N-E (21.9%, p = 0.003) and S-E (22.0%, p = 0.014). Compared to W-E, adjusted mortality in N-E (HR 0.85, p = 0.019) and S-E (HR 0.72, p = 0.043) remain significantly lower after adjustment for pre- and peri-procedural factors, but no significant interaction (Pinteraction = 0.728) between region and modality of revascularization was seen.
Conclusion:
In the era of globalization, knowledge, and understanding of geographic disparity are of paramount importance for the correct interpretation of global studies.
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