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Major cardiovascular events at 5 years in surgical versus percutaneous revascularization for left main stem disease: an updated meta-analysis.

ABSTRACT: The aim of the present study was to analyse the incidence of major adverse cardiovascular events in patients undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary intervention with drug-eluting stents for left main stem disease. Five manuscripts publishing 5-year results of 4 trials (SYNTAX, PRECOMBAT, NOBLE and EXCEL) were included. Overall meta-analysis with inclusion of the 5-year results from the EXCEL trial using the protocol definition for myocardial infarction showed that CABG is associated with a significant reduction in the risk of major adverse cardiovascular events (MACE) (risk ratio = 0.74; 95% confidence interval = 0.68-0.80). When the universal definition was used to define myocardial infarction in the EXCEL trial, the analysis demonstrated a larger benefit of coronary surgery in terms of reduction in the risk of MACE (risk ratio = 0.70; 95% confidence interval = 0.63-0.76). Non-significant differences were detected in terms of risk of overall mortality, cardiac mortality or stroke. In conclusion, this meta-analysis shows that CABG significantly reduces the risk of MACE in patients with left main stem disease. The inclusion of the 5-year results of the EXCEL trial using third universal definition amplifies the benefit of CABG over percutaneous coronary intervention.

SUBMITTER: Urso S

PROVIDER: S-EPMC8906685 | biostudies-literature | 2021 Apr

REPOSITORIES: biostudies-literature

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Major cardiovascular events at 5 years in surgical versus percutaneous revascularization for left main stem disease: an updated meta-analysis.

Urso Stefano S Sadaba Rafel R Nogales Eliú E González Jesús María JM Tena María Ángeles MÁ Paredes Federico F González-Barbeito Miguel M Portela Francisco F

Interactive cardiovascular and thoracic surgery 20210401 4

The aim of the present study was to analyse the incidence of major adverse cardiovascular events in patients undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary intervention with drug-eluting stents for left main stem disease. Five manuscripts publishing 5-year results of 4 trials (SYNTAX, PRECOMBAT, NOBLE and EXCEL) were included. Overall meta-analysis with inclusion of the 5-year results from the EXCEL trial using the protocol definition for myocardial infarction ...[more]

PMID: 33881148

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Project description:AimsA 5-year survival of patients with unprotected left main (ULM) stenosis according to the choice of revascularization (percutaneous vs. surgical) remains to be defined.Methods and resultsRandomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) vs. coronary artery bypass graft (CABG) with a follow-up of at least 5 years were included. All-cause death was the primary endpoint. MACCE [a composite endpoint of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization] along with its single components and cardiovascular (CV) death were the secondary ones. Analyses were stratified according to the use of first- vs. last-generation coronary stents. Subgroup comparisons were performed according to SYNTAX score (below or above 33) and to age (using cut-offs of each trial's subgroup analysis). Four RCTs with 4394 patients were identified: 2197 were treated with CABG, 657 with first generation, and 1540 with last-generation stents. At 5-year rates of all-cause death did not differ [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.71-1.21], as those of CV death and stroke. Coronary artery bypass graft reduced rates of MACCE (OR 0.69, 95% CI 0.60-0.79), mainly driven by MI (OR 0.48, 95% CI 0.36-0.65) and revascularization (OR 0.53, 95% CI 0.45-0.64). Benefit of CABG for MACCE was consistent, although with different extent, across values of SYNTAX score (OR 0.76, 95% CI 0.59-0.97 for values < 32 and OR 0.63, 95% CI 0.47-0.84 for values ≥ 33) while was not evident for 'younger' patients (OR 0.83, 95% CI 0.65-1.07 vs. OR 0.65, 95% CI 0.51-0.84 for 'older' patients).ConclusionFor patients with ULM disease followed-up for 5 years, no significant difference was observed in all-cause and cardiovascular death between PCI and CABG. Coronary artery bypass graft reduced risk of MI, revascularization, and MACCE especially in older patients and in those with complex coronary disease and a high SYNTAX score.

Project description:ObjectiveObstructive sleep apnea (OSA) is common in peripheral arterial disease (PAD) and associates with high mortality after surgery. Since abnormal heart rate variability (HRV) is predictive of postoperative complications, we investigated the relations of HRV with PAD, OSA and major adverse cardiovascular and cerebrovascular events (MACCE).Materials and methodsSeventy-five patients (67±9 years) scheduled for sub-inguinal revascularization and 15 controls (63±6 years) underwent polysomnography and HRV analyses. OSA with an apnea-hypopnea index (AHI) ≥20/hour was considered significant. HRV was measured during wakefulness, S2, S3-4 and rapid eye movement (REM) sleep with time and frequency domain methods including beat-to-beat variability, low frequency (LF) and high frequency (HF) power, and detrended fluctuation analysis (DFA). MACCE was defined as cardiac death, myocardial infarction, coronary revascularization, hospitalized angina pectoris and stroke.ResultsThirty-six patients (48%) had AHI≥20/hour. During follow-up (median 52 months), 22 patients (29%) suffered a MACCE. Compared to controls, fractal correlation of HRV (scaling exponent alpha 1 measured with DFA) was weaker during S2 and evening wakefulness in all subgroups (+/-AHI≥20/hour, +/-MACCE) but only in patients with AHI≥20/hour during morning wakefulness. The LF/HF ratio was lower in all subgroups during S2 but only in patients with AHI ≥20/hour during evening or morning wake. In the covariance analysis adjusted for age, body mass index, coronary artery disease and PAD duration, the alpha 1 during morning wakefulness remained significantly lower in patients with AHI≥20/hour than in those without (1.12 vs. 1.45; p = 0.03). Decreased HF during REM (p = 0.04) and S3-4 sleep (p = 0.03) were predictive of MACCE. In analyses with all sleep stages combined, mean heart rate as well as very low frequency, LF, HF and total power were associated with OSA of mild-to-moderate severity (AHI 10-20/hour).ConclusionsHRV is altered in patients with PAD. These alterations have a limited association with OSA and MACCE.

Project description:BackgroundThe number of models developed for predicting major adverse cardiovascular events (MACE) in patients undergoing percutaneous coronary intervention (PCI) is increasing, but the performance of these models is unknown. The purpose of this systematic review is to evaluate, describe, and compare existing models and analyze the factors that can predict outcomes.MethodsWe adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 during the execution of this review. Databases including Embase, PubMed, The Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP, and SINOMED were comprehensively searched for identifying studies published from 1977 to 19 May 2023. Model development studies specifically designed for assessing the occurrence of MACE after PCI with or without external validation were included. Bias and transparency were evaluated by the Prediction Model Risk Of Bias Assessment Tool (PROBAST) and Transparent Reporting of a multivariate Individual Prognosis Or Diagnosis (TRIPOD) statement. The key findings were narratively summarized and presented in tables.ResultsA total of 5,234 articles were retrieved, and after thorough screening, 23 studies that met the predefined inclusion criteria were ultimately included. The models were mainly constructed using data from individuals diagnosed with ST-segment elevation myocardial infarction (STEMI). The discrimination of the models, as measured by the area under the curve (AUC) or C-index, varied between 0.638 and 0.96. The commonly used predictor variables include LVEF, age, Killip classification, diabetes, and various others. All models were determined to have a high risk of bias, and their adherence to the TRIPOD items was reported to be over 60%.ConclusionThe existing models show some predictive ability, but all have a high risk of bias due to methodological shortcomings. This suggests that investigators should follow guidelines to develop high-quality models for better clinical service and dissemination.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=400835, Identifier CRD42023400835.

Dataset Information

Major cardiovascular events at 5 years in surgical versus percutaneous revascularization for left main stem disease: an updated meta-analysis.

Publications

Major cardiovascular events at 5 years in surgical versus percutaneous revascularization for left main stem disease: an updated meta-analysis.

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