High-risk patients ineligible for bypass surgery see ‘profound improvements’ after PCI
Percutaneous coronary intervention (PCI) is associated with significant short-term improvements in high-risk patients with complex coronary artery disease (CAD) who are ineligible for coronary artery bypass grafting (CABG), according to a new analysis published in JACC: Cardiovascular Interventions.[1]
“Patients with left main and/or multivessel CAD at prohibitive surgical risk represent the confluence of complex coexisting illness frailty, and complex anatomy and present an increasingly common clinical dilemma,” wrote first author Adam Salisbury, MD, an interventional cardiologist with Saint Luke’s Mid America Heart Institute in Kansas City, Missouri, and colleagues. “Considering the absent representation of these individuals in prior trials, there are few data to inform the development of guideline recommendations for treatment of these patients.”
Hoping to learn more about how these high-risk patients with complex CAD typically respond to PCI, Salisbury et al. examined data from more than 700 patients who were treated from December 2016 to July 2019. All patients were ineligible for CABG. In addition to undergoing PCI, each patient also received guideline-recommended medical therapy.
The mean patient age was 70 years old, 32.8% of patients had a history of prior PCI and 16.4% had a history of prior CABG. A majority (83.2%) of patients underwent a single PCI procedure, an additional 15.4% underwent two procedures and 1.4% underwent three. The most common indications for revascularization among these patients were the treatment of ischemic symptoms, ischemic cardiomyopathy and treatment of an acute coronary syndrome. Nearly half (45.3%) of patients presented with high-complexity CAD based on SYNTAX scores.
Overall, all-cause mortality was 5.6% after 30 days and 12.3% after six months. These percentages were similar to predictions made by surgical risk models, but lower than surgeon estimates. While the mean baseline SYNXTAX score was 32.4 ± 12.2 among these patients, the mean SYNTAX score following PCI was 15 ± 11.7. Also, the authors noted, “profound improvements” were in seen in patient-reported health status, especially when focused on CAD-specific and heart failure-specific symptoms.
“These findings underscore that these challenging patients are frequently highly symptomatic at baseline and have potential to experience very large health status benefits,” the authors wrote.
Reviewing their findings, the researchers noted that better risk prediction tools are needed for evaluating high-risk patients with complex CAD.
“Because mortality risk is high, but likelihood of dramatic health status improvement is also high, incorporating both outcomes is of key importance,” the group wrote. “In contrast to younger, ‘healthier’ CAD patients, patients at high surgical risk are often older with advanced comorbidities. For these patients, improving quality of life is often their primary goal of care.”
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.