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Incidence, Predictors, and Impact of Hospital Readmission After Revascularization for Left Main Coronary Disease
Ioanna Kosmidou1, Bahira Shahim2, Ovidiu Dressler2
1Memorial Sloan Kettering Cancer Center, New York and Weill Cornell College of Medicine, New York, New York, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.
Insights
Hospital readmissions after left main coronary artery disease (LMCAD) revascularization are common, occurring more frequently after percutaneous coronary intervention (PCI) than coronary artery bypass grafting (CABG). These readmissions increase the risk of death, particularly following PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- The frequency and impact of hospital readmissions following revascularization for left main coronary artery disease (LMCAD) remain unclear.
- Understanding readmission patterns is crucial for optimizing patient outcomes after LMCAD treatment.
Purpose of the Study:
- To investigate the incidence, predictors, and clinical significance of readmissions after percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for LMCAD.
- To analyze the impact of readmissions on subsequent mortality within a 5-year follow-up period.
Main Methods:
- Analysis of data from the EXCEL trial, randomizing 1,905 patients with LMCAD to PCI or CABG.
- Utilized multivariable Anderson-Gill and joint frailty models to assess cumulative readmission incidence and competing risks.
- Employed time-adjusted Cox proportional hazards models to determine the association between readmission and mortality.
Main Results:
- Within 5 years, 45.2% of survivors experienced 1,868 readmissions (mean 2.2 per patient), with equal distribution between cardiovascular and non-cardiovascular causes.
- Readmissions were more frequent after PCI (48.6%) compared to CABG (41.8%) (P=0.003).
- PCI independently predicted readmission (aHR 1.22), alongside female sex, comorbidities, and CAD extent. Readmission was linked to increased all-cause death, with a higher risk post-PCI (aHR 5.72) versus CABG (aHR 2.72).
Conclusions:
- Readmissions following LMCAD revascularization in the EXCEL trial were frequent and higher in the PCI group compared to the CABG group.
- Readmissions were independently associated with an increased risk of all-cause mortality, a risk amplified after PCI compared to CABG.
Background:
The frequency of and relationship between hospital readmissions and outcomes after revascularization for left main coronary artery disease (LMCAD) are unknown.
Objectives:
The purpose of this study was to study the incidence, predictors, and clinical impact of readmissions following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for LMCAD.
Methods:
In the EXCEL (XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, 1,905 patients with LMCAD were randomized to PCI vs CABG. The cumulative incidence of readmissions was analyzed with multivariable Anderson-Gill and joint frailty models to account for recurrent events and the competing risk of death. The impact of readmission on subsequent mortality within 5-year follow-up was determined in a time-adjusted Cox proportional hazards model.
Results:
Within 5 years, 1,868 readmissions occurred in 851 of 1,882 (45.2%) hospital survivors (2.2 ± 1.9 per patient with readmission[s], range 1-16), approximately one-half for cardiovascular causes and one-half for noncardiovascular causes (927 [49.6%] and 941 [50.4%], respectively). One or more readmissions occurred in 463 of 942 (48.6%) PCI patients vs 388 of 940 (41.8%) CABG patients (P = 0.003). After multivariable adjustment, PCI remained an independent predictor of readmission (adjusted HR: 1.22; 95% CI: 1.10-1.35; P < 0.0001), along with female sex, comorbidities, and the extent of CAD. Readmission was independently associated with subsequent all-cause death, with interaction testing indicating a higher risk after PCI than CABG (adjusted HR: 5.72; 95% CI: 3.42-9.55 vs adjusted HR: 2.72; 95% CI: 1.64-4.88, respectively; Pint = 0.03).
Conclusions:
In the EXCEL trial, readmissions during 5-year follow-up after revascularization for LMCAD were common and more frequent after PCI than CABG. Readmissions were associated with an increased risk of all-cause death, more so after PCI than with CABG.
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