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Spontaneous Myocardial Infarction After Left Main Revascularization: The EXCEL Trial
Mahesh V Madhavan1,2, John Gregson3, Bjorn Redfors2,4,5
1New York-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, NY (M.V.M.).
Insights
Spontaneous myocardial infarction (MI) occurred more often after percutaneous coronary intervention (PCI) than coronary artery bypass graft (CABG) surgery for left main coronary artery disease. This MI independently predicted higher mortality risk following either procedure.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Limited data exist on spontaneous myocardial infarction (MI) rates and outcomes after left main coronary artery disease (LMCAD) revascularization.
- Comparing spontaneous MI after percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) is crucial for understanding long-term prognosis.
Purpose of the Study:
- To compare the rates of spontaneous MI after PCI versus CABG for LMCAD.
- To evaluate the prognostic implications of spontaneous MI on cardiovascular and all-cause mortality within 5 years post-revascularization.
Main Methods:
- Analysis of spontaneous and procedural MI from the EXCEL trial (N=1882) for patients with LMCAD.
- Cox proportional hazards regression used to assess the association between MI and 5-year mortality outcomes.
Main Results:
- Spontaneous MI occurred in 6.8% after PCI versus 3.4% after CABG (adjHR, 2.01; P=0.002).
- Spontaneous MI independently predicted increased cardiovascular (adjHR, 9.39) and all-cause mortality (adjHR, 4.77) at 5 years.
- Procedural MI was also associated with increased mortality, but less strongly than spontaneous MI.
Conclusions:
- Spontaneous MI is more frequent after PCI than CABG for LMCAD revascularization.
- Spontaneous MI significantly increases long-term mortality risk, irrespective of the revascularization strategy.
- Spontaneous MI carries a higher mortality risk than large procedural MI.
Background:
Limited data are available regarding the relative rates, etiology, and long-term prognostic implications of spontaneous myocardial infarction (MI) after percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery for left main coronary artery disease (LMCAD).
Methods:
MIs after PCI and CABG for LMCAD were adjudicated from the EXCEL trial (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). Cox proportional hazards regression was performed to assess the association between spontaneous (and procedural) MI and cardiovascular and all-cause mortality at 5 years.
Results:
Among 1882 patients who underwent LMCAD revascularization, spontaneous MI during 5-year follow-up occurred in 60 (6.8%) patients after PCI and in 29 (3.4%) patients after CABG (adjusted hazard ratio [adjHR], 2.01; 95 CI, 1.29-3.15; P=0.002). By multivariable analysis, spontaneous MI (as a time-adjusted covariate) was a strong independent predictor of subsequent cardiovascular mortality (adjHR, 9.39; 95% CI, 5.22-16.87) and all-cause mortality (adjHR, 4.77; 95% CI, 2.92-7.80) within 5 years, with consistent effects after PCI and CABG (Pinteraction=0.60 and 0.78, respectively). In the same models, procedural MI as defined by extensive myonecrosis was associated with 5-year cardiovascular (adjHR, 3.02; 95% CI, 1.64-5.56) and all-cause mortality (adjHR, 2.38; 95% CI, 1.48-3.80), with consistent effects after PCI and CABG (Pinteraction=0.23 and 0.34, respectively).
Conclusions:
In the EXCEL trial, spontaneous MI occurred relatively infrequently within 5 years after LMCAD revascularization but at a higher rate after PCI compared with CABG. Spontaneous MI after revascularization was strongly related to subsequent cardiovascular and all-cause mortality, consistently after PCI and CABG, and was more strongly associated with mortality than was large procedural MI.
Registration:
URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01205776.
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