Surgery, Percutaneous Intervention, and Medical Treatment in Cases with Chronic Coronary Syndrome with High Syntax Scores

Year 2022, Volume: 44 Issue: 3, 405 - 413, 14.03.2022

Kamal Isgandarov , Kadir Uğur Mert

https://doi.org/10.20515/otd.1001126

Abstract

Generally, surgical revascularization recommended for patients who have high SYNTAX scores, but it is the greatest desire of invasive cardiologists to have a reliable “Plan B” in cases with high surgery risk. For this reason, the purpose of the present study was to compare medical treatment alone, surgical-medical treatment, and percutaneous-medical treatment options in CCS cases with a SYNTAX score of ≥33. In an observational registry study, we included patients with multivessel disease and SYNTAX score of ≥33. Both short (30-day) and long-term outcomes of subjects in all three treatment arms were evaluated. The primary outcome was allcause and cardiac mortality. Myocardial infarction, revascularization, and stroke constituted our secondary outcomes. 33 patients in the MT arm, 24 in the PCI arm, and 79 in the CABG arm were included in the analyses. Mean follow-up was 48.25±26.37 months. CABG arm was superior to both arms in terms of cardiac death (CABG vs MT p=0.001, CABG vs PCI p=0.001) and PCI and MT did were similar (p=0.085), CABG was superior in allcause detah (CABG vs MT p=0.002, CABG vs PCI p=0.002) again no statistical differences were detected between MT and PCI arms (p=0.065) in long term follow-up. In terms of acute myocardial infarction(AMI) (CABG vs MT p=<0.001, CABG vs PCI p=<0.001), cerebrovascular event(CVE) (CABG vs MT p=0.04, CABG vs PCI p=0.015) , additional revascularization CABG was superior side again (CABG vs PCI p=<0.001). AMI was higher in MT group compare to PCI (p=0.025). CVE were similar in MT and PCI groups (p=0.65). İn cases with CCS and ≥33 SYNTAX score, CABG is superior to MT alone and PCI which is performed with everolimus-eluting stents in terms of cardiac death, allcause mortality, AMI and CVE in long term follow-up.

Keywords

Coronary artery bypass, Everolimus, Percutaneous coronary intervention, SYNTAX score, Multivessel disease

Yüksek Syntax Skoruna Sahip Kronik Koroner Sendromlu Olgularda Cerrahi, Perkütan Müdahale ve Medikal Tedavi

Abstract

Yüksek SYNTAX skorlu olgulara genellikle cerrahi revaskülarizasyon önerilmektedir ve cerrahi riski yüksek olgularda güvenilir bir “B planı”nın olması girişimsel kardiologların en büyük arzusudur. Bu sebeple çalışmamızda kronik koroner sendrom (KKS)’lu SYNTAX skoru ≥33 olan olgularda tek başına medikal tedavi(MT), cerrahi-medikal tedavi(CABG) ve perkütan-medikal tedavi(PCI) kollarını karşılaştırmayı amaçladık. Gözlemsel kayıt çalışmamıza KKS’li çok damar hastası ve SYNTAX skoru ≥33 olan olgular dahil edildi. Her üç tedavi kolundaki olguların hem kısa (30 günlük) hem de uzun dönem sonlanımları değerlendirildi. Birincil sonlanım noktası kardiyak ve tüm nedenlere bağlı mortalite iken, ikincil sonlanım noktası akut miyokart infarktüsü(AMİ), ilave revaskülarizasyon, serebrovasküler olay( SVO) olarak belirlendi. 33 hasta MT, 24 hasta PCI, 79 hasta ise CABG kolunda istatistiksel analize dahil edildi. Ortalama takip süresi 48,25±26,37 ay olarak saptandı. Uzun dönemde CABG kardiyak ve tüm nedenlere bağlı ölüm açısından MT ve PCI kollarına üstün olduğu görüldü(sırasıyla CABG vs MT p=0,001, CABG vs PCI p=0,001; CABG vs MT p=0,002, CABG vs PCI p=0,002). Bu bağlamda MT ve PCI kolları arasında fark görülmedi (sırasıyla p=0,085, p=0,065). AMİ ve SVO sonlanım noktalarında da CABG kolunun superior olduğu saptandı(sırasıyla CABG vs MT p=<0,001, CABG vs PCI p=<0,001; CABG vs MT p=0,04, CABG vs PCI p=0,015). CABG kolu ilave revaskülarizasyon açısından da PCI’a üstün bulundu(p=<0,001). AMİ MT’de PCI koluna göre daha fazla görülürken (p=0,025), SVO açısından iki kol arasında fark görülmedi(p=0,65) daha fazl İlave revaskülarizasyon açısından da yine CABG daha üstün olarak görüldü(CABG vs PCI p=<0,001) KKS’lu SYNTAX skoru ≥33 olan olgularda CABG, tek başına MT ve everolimus kaplı stentlerle yapılan PCI’ya göre uzun dönemde kardiyak ölüm, tüm nedenlere bağlı ölüm, AMİ ve SVO açısından daha üstündür.

Keywords

Koroner bypass, Everolimus, Perkütan koroner müdahale, Syntax skoru, çok damar hastalığı.

References

• 1. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019;40:87-165.
• 2. Spertus JA, Salisbury AC, Jones PG et al. Predictors of quality-of-life benefit after percutaneous coronary intervention. Circulation 2004;110:3789-3794.
• 3. Steg PG, Greenlaw N, Tendera M, et al. Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) Investigators. Prevalence of anginal symptoms and myocardial ischemia and their effect on clinical outcomes in outpatients with stable coronary artery disease: data from the International Observational CLARIFY Registry. JAMA Intern Med 2014;174:1651-1659.
• 4. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020 Jan 14;41(3):407-477. doi: 10.1093/eurheartj/ehz425.
• 5. Farooq V, Serruys PW, Garcia-Garcia HM, et al. The negative impact of incomplete angiographic revascularization on clinical outcomes and its association with total occlusions: The SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial. J Am Coll Cardiol 2013;61:282–294.
• 6. Garcia S, Sandoval Y, Roukoz H, et al. Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: A meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol 2013;62:1421–1431.
• 7. Farooq V, Serruys PW, Bourantas CV, et al. Quantification of incomplete revascularization and its association with five-year mortality in the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) trial validation of the residual SYNTAX score. Circulation 2013;128:141–151.
• 8. Bangalore S, Guo Y, Samadashvili Z, et al. Everolimuseluting stents or bypass surgery for multivessel coronary disease. N Engl J Med 2015;372:1213–1222.
• 9. Ahn JM, Park DW, Lee CW et al. Comparison of stenting versus bypass surgery according to the completeness of revascularization in severe coronary artery disease: Patientlevel pooled analysis of the SYNTAX, PRECOMBAT, and BEST Trials. JACC Cardiovasc Interv 2017;10:1415–1424.
• 10. Bangalore S, Toklu B, Amoroso N, et al. Bare metal stents, durable polymer drug eluting stents, and biodegradable polymer drug eluting stents for coronary artery disease: mixed treatment comparison meta-analysis. BMJ 2013;347:f6625.
• 11. Sarno G, Lagerqvist B, Fröbert O, et al. Lower risk of stent thrombosis and restenosis with unrestricted use of ‘newgeneration’ drug-eluting stents:a report from the nationwide Swedish Coronary Angiography and Angioplasty Registry(SCAAR).Eur Heart J2012;33:606-13
• 12. Bangalore S, Guo Y, Samadashvili Z, et al. Everolimus-eluting Stents or Bypass Surgery for Multivessel Coronary Disease. N Engl J Med 2015 Mar 26;372(13):1213-22.
• 13. Belsey J, Savelieva I, Mugelli A, Camm AJ. Relative efficacy of antianginal drugs used as add-on therapy in patients with stable angina: a systematic review and meta-analysis. Eur J Prev Cardiol 2015;22:837-848.
• 14. Spadaccio C, Benedetto U. Coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) in the treatment of multivessel coronary disease: quo vadis? —a review of the evidences on coronary artery disease. Ann Cardiothorac Surg 2018;7(4):506-515. doi: 10.21037/acs.2018.05.17.
• 15. Thygesen K, Alpert JS, Jaffe AS, et al., for the Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol 2018;72: 2231–64.
• 16. Windecker S, Stortecky S, Stefanini GG et al. Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis. BMJ 2014;348:g3859.
• 17. Chang M, Ahn JM, Lee CW et all . Long-Term Mortality After Coronary Revascularization in Nondiabetic Patients With Multivessel Disease. JACC 2016 vol. 68, no 1.
• 18. BARI Investigators. The final 10-year follow-up results from the BARI randomized trial. J Am Coll Cardiol 2007;49:1600–6.
• 19. Farkouh ME, Domanski M, Sleeper LA, et al., FREEDOM Trial Investigators. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 2012;367:2375–84.
• 20. Sipahi I, Akay MH, Dagdelen S, et al. Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era. JAMA Intern Med 2014;174: 223–30.
• 21. Head SJ, Davierwala PM, Serruys PW, et al. Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with threevessel disease: final five-year follow-up of the SYNTAX trial. Eur Heart J 2014;35:2821–30.
• 22. Weintraub WS, Grau-Sepulveda MV, Weiss JM, et al. Comparative effectiveness of revascularization strategies. N Engl J Med 2012;366:1467–76.
• 23. Wang JC, Normand SLT, Mauri L, et al. Coronary artery spatial distribution of acute myocardial infarction occlusions. Circulation 2004;110: 278–84.
• 24. Gersh BJ, Frye RL. Methods of coronary revascularization—things may not be as they seem. N Engl J Med 2005;352:2235–7.
• 25. Cristiano Spadaccio, Umberto Benedetto. Coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) in the treatment of multivessel coronary disease: quo vadis? -a review of the evidences on coronary artery disease. Ann Cardiothorac Surg. 2018 Jul;7(4):506-515.
• 26. Athappan G, Chacko P, Patvardhan E, et al. Late stroke: comparison of percutaneous coronary intervention versus coronary artery bypass grafting in patients with multivessel disease and unprotected left main disease: a meta-analysis and review of literature. Stroke 2014;45:185–93.
• 27. Marui A, Kimura T, Tanaka S, et al., CREDOKyoto Investigators. Comparison of frequency of postoperative stroke in off-pump coronary artery bypass grafting versus on-pump coronary artery bypass grafting versus percutaneous coronary intervention. Am J Cardiol 2012;110:1773–8.