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Published on: March 27, 2018
Health Status Outcomes With Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting in ISCHEMIA
Chetan P Huded1,2, John A Spertus1,2, Philip G Jones1,2
1Saint Luke's Mid America Heart Institute, Kansas City, MO (C.P.H., J.A.S., P.G.J.).
Insights
Invasive strategies like percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) improved health status in chronic coronary disease patients compared to conservative care. While both procedures offered benefits, CABG showed greater angina relief at one year, but this difference diminished by three years.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- The ISCHEMIA trial previously showed invasive strategies improve health status in chronic coronary disease (CCD).
- Prior research suggests coronary artery bypass grafting (CABG) may offer superior health status benefits over percutaneous coronary intervention (PCI).
- It remains unclear if CABG primarily drove the benefits of invasive management observed in the ISCHEMIA trial.
Purpose of the Study:
- To compare health status outcomes between conservative management, PCI, and CABG in ISCHEMIA trial participants.
- To evaluate the Seattle Angina Questionnaire-7 summary score (SAQ-SS) and angina frequency score (SAQ-AF) as primary outcomes.
- To determine if specific invasive strategies (PCI vs. CABG) influenced health status improvements.
Main Methods:
- Analysis of 3,200+ participants from the ISCHEMIA trial: conservative (n=2232), PCI (n=1198), and CABG (n=340).
- Primary outcomes: SAQ-SS and SAQ-AF at 1 and 3 years, with higher scores indicating better status.
- Risk-adjusted proportional odds models were used to compare outcomes, controlling for patient characteristics.
Main Results:
- Both PCI and CABG groups showed significant improvements in SAQ-SS and SAQ-AF compared to the conservative group at 1 and 3 years.
- At 1 year, CABG demonstrated significantly better angina relief (SAQ-AF) than PCI (OR, 1.54).
- By 3 years, no significant differences in SAQ-SS or SAQ-AF were observed between CABG and PCI.
Conclusions:
- Both PCI and CABG significantly enhance 3-year health status in patients with CCD compared to conservative management.
- While CABG provided superior angina relief at 1 year, this advantage was not sustained at 3 years.
- The findings support the use of invasive strategies, including both PCI and CABG, for improving patient-reported health status in CCD.
Background:
In ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), an invasive strategy demonstrated better health status outcomes than a conservative strategy in patients with chronic coronary disease (CCD). Some previous studies have shown greater health status benefits with coronary artery bypass grafting (CABG) than percutaneous coronary intervention (PCI). Whether the health status benefits of invasive management in ISCHEMIA were driven primarily by participants treated with CABG is unknown.
Methods:
The aim of this analysis was to describe the health status outcomes of participants treated with a conservative strategy (n=2232) compared with invasively managed participants treated with PCI (n=1198) or CABG (n=340) in ISCHEMIA. The Seattle Angina Questionnaire-7 summary score (SAQ-SS) and angina frequency score (SAQ-AF) were the primary outcomes, with higher scores indicating better health status. Proportional odds models comparing 1- and 3-year outcomes were fit, adjusting for demographic, clinical, and angiographic characteristics.
Results:
SAQ-SS in the conservative, PCI, and CABG groups increased by 9.9±18.1, 15.7±19.3, and 16.1±19.1 points at 1 year and 11.5±20.2, 16.5±21.8, and 15.0±19.4 points at 3 years, respectively. Freedom from angina in the conservative, PCI, and CABG groups was noted in 61.4%, 73.3%, and 82.4% at 1 year and 70.4%, 76.1%, 81.4% at 3 years, respectively. In risk-adjusted analyses, PCI and CABG were each associated with a higher SAQ-SS and SAQ-AF at 1 and 3 years compared with conservative management. SAQ-AF was higher with CABG than PCI at 1 year (odds ratio, 1.54 [95% CI, 1.03, 2.31]), but no differences between CABG and PCI were observed in SAQ-SS (odds ratio, 1.11 [95% CI, 0.78, 1.57]) or SAQ-AF (odds ratio, 0.94 [95% CI, 0.58, 1.54]) at 3 years.
Conclusions:
In ISCHEMIA, both PCI and CABG were associated with better 3-year health status than conservative management. Better angina relief with CABG than PCI was seen at 1, but not 3, years.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.
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