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Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Surgical Risk and Long-Term Mortality With PCI and CABG in Ischemic Left Ventricular Systolic Dysfunction
Guillaume Marquis-Gravel1, Guangyu Tong2, Matthew Dodd3
1Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada.
Insights
Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) revascularization effects for ischemic left ventricular systolic dysfunction (iLVSD) are not influenced by baseline surgical risk. Both CABG and PCI showed consistent outcomes regardless of patient risk stratification.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Ischemic left ventricular systolic dysfunction (iLVSD) patients benefit from coronary artery bypass grafting (CABG) over optimal medical therapy (OMT), but percutaneous coronary intervention (PCI) offers no clear advantage.
- Randomized controlled trials (RCTs) comparing revascularization strategies may have varying baseline surgical risk profiles.
- Investigating the influence of baseline surgical risk on treatment effects is crucial for understanding revascularization outcomes in iLVSD.
Purpose of the Study:
- To determine if baseline surgical risk modifies the treatment effect of PCI versus OMT in patients with iLVSD.
- To assess whether baseline surgical risk impacts the effectiveness of CABG compared to OMT in iLVSD patients.
- To analyze the interaction between revascularization strategy (PCI or CABG) and surgical risk on all-cause mortality.
Main Methods:
- Post hoc analysis of the REVIVED-BCIS2 (PCI vs. OMT) and STICH (CABG vs. OMT) RCTs involving patients with iLVSD.
- All-cause mortality was the primary outcome measure.
- Baseline surgical risk was estimated using a modified European System for Cardiac Operative Risk Evaluation (EuroSCORE)-II, and its interaction with treatment was quantified.
Main Results:
- The REVIVED-BCIS2 trial (n=666) showed PCI had no significant effect on mortality versus OMT across all baseline surgical risk tertiles (P interaction = .79).
- The STICH trial (n=1200) demonstrated that CABG consistently reduced mortality compared to OMT across all baseline surgical risk tertiles (P interaction = .64).
- Participants in the REVIVED-BCIS2 trial had a higher proportion in the highest baseline EuroSCORE-II tertile compared to the STICH trial (40.4% vs. 29.4%).
Conclusions:
- The treatment effect of PCI versus OMT for iLVSD is not modified by baseline surgical risk.
- The mortality benefit of CABG versus OMT in iLVSD patients is consistent across varying levels of baseline surgical risk.
- These findings, from two large RCTs, suggest baseline surgical risk does not alter the comparative effectiveness of PCI or CABG against OMT in iLVSD.
Background:
Coronary artery bypass grafting (CABG) improves survival compared with optimal medical therapy (OMT) alone in patients with ischemic left ventricular systolic dysfunction (iLVSD), but percutaneous coronary intervention (PCI) did not show clinical benefits in this population. However, the randomized controlled trials (RCT) evaluating these 2 revascularization modalities may differ in terms of baseline surgical risk. The aim is to investigate whether the treatment effects of PCI vs OMT, and of CABG vs OMT, are modified by baseline surgical risk.
Methods:
A post hoc analysis of the Revascularization for Ischemic Ventricular Dysfunction - British Cardiovascular Intervention Society 2 (REVIVED-BCIS2) and Surgical Treatment for Ischemic Heart Failure (STICH) RCT comparing PCI and CABG vs OMT, respectively, in patients with iLVSD, was conducted. The main outcome was all-cause mortality. Interaction between randomized treatment and baseline surgical risk, estimated by a modified European System for Cardiac Operative Risk Evaluation (EuroSCORE)-II, was quantified.
Results:
A total of 666 participants from the REVIVED-BCIS2 trial and 1200 participants from the STICH trial were included. Participants from the REVIVED-BCIS2 trial were more likely to be in the highest tertile of baseline EuroSCORE-II (40.4% vs 29.4%, respectively; P < .001). In the REVIVED-BCIS2 trial, PCI had a consistent lack of effect on all-cause mortality vs OMT across baseline EuroSCORE-II tertiles (P for interaction = .79). In the STICH trial, CABG reduced mortality consistently vs OMT across baseline EuroSCORE-II tertiles (P for interaction = .64).
Conclusions:
In the 2 largest RCT evaluating the impact of revascularization in iLVSD and multivessel coronary disease, the treatment effect of PCI vs OMT, and of CABG vs OMT, was not modified by baseline surgical risk.
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