Lack of implementation of guidelines recommendations for coronary revascularization in stable patients with complex disease is associated with high rates of incomplete revascularization

Analysis from the Apache study

Marcello Marino, Sergio Leonardi, Gabriele Crimi, Maurizio Ferrario, Giuseppe Musumeci, Giuseppe Tarantini, Corrado Lettieri, Luca Bettari, Lettino Maddalena, Leonardo De Luca, Ferdinando Varbella, Stefano De Servi

Research output: Contribution to journalArticle

Abstract

The objective of this study is to evaluate completeness of coronary revascularization in patients with complex stable coronary artery disease (SCAD) who underwent percutaneous coronary interventions (PCI), but a surgical revascularization indicated according to 2018 European Society of Cardiology guidelines. The optimal mode of revascularization for SCAD should take into account clinical, anatomic, and procedural characteristics—including anticipated completeness of revascularization—and modality of treatment should be discussed by a Heart Team. Among patients enrolled in the APpropriAteness of percutaneous Coronary interventions in patients with ischemic heart disease study, we identified patients with complex SCAD. Rates of ad-hoc PCI and documented heart team discussion were reported stratified by guideline recommended mode of revascularization. Completeness of revascularization was assessed by an angiographic core laboratory using residual SS (rSS) ≤ 8 and SYNTAX Revascularization Index (SRI) ≥ 70%. Among 336 PCI patients with SCAD, 182 (54.2%) had complex coronary disease and 152 underwent ad-hoc PCI (83.5%). Patients for whom surgery was the recommended revascularization option (9.3%) had a significantly and substantial higher rate of incomplete revascularization than patients for whom either mode of revascularization or PCI was recommended (61.3% vs 23.6% with rSS > 8, p < 0.001 and 77.4% vs 44.6% with SRI < 70%, p < 0.001). Patients with complex SCAD receiving percutaneous myocardial revascularization when surgery was recommended have substantially incomplete myocardial revascularization. These data support multidisciplinary decision-making in these patients and suggest considering anticipated completeness when deciding mode of coronary revascularization.

Original languageEnglish
JournalHeart and Vessels
DOIs
Publication statusPublished - Jan 1 2019

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Guidelines
Percutaneous Coronary Intervention
Coronary Artery Disease
Myocardial Revascularization
Myocardial Ischemia
Coronary Disease
Decision Making

Keywords

  • Complete revascularization
  • Coronary artery bypass graft
  • Coronary disease
  • Percutaneous coronary intervention
  • Revascularization appropriateness

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Lack of implementation of guidelines recommendations for coronary revascularization in stable patients with complex disease is associated with high rates of incomplete revascularization : Analysis from the Apache study. / Marino, Marcello; Leonardi, Sergio; Crimi, Gabriele; Ferrario, Maurizio; Musumeci, Giuseppe; Tarantini, Giuseppe; Lettieri, Corrado; Bettari, Luca; Maddalena, Lettino; De Luca, Leonardo; Varbella, Ferdinando; De Servi, Stefano.

In: Heart and Vessels, 01.01.2019.

Research output: Contribution to journalArticle

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abstract = "The objective of this study is to evaluate completeness of coronary revascularization in patients with complex stable coronary artery disease (SCAD) who underwent percutaneous coronary interventions (PCI), but a surgical revascularization indicated according to 2018 European Society of Cardiology guidelines. The optimal mode of revascularization for SCAD should take into account clinical, anatomic, and procedural characteristics—including anticipated completeness of revascularization—and modality of treatment should be discussed by a Heart Team. Among patients enrolled in the APpropriAteness of percutaneous Coronary interventions in patients with ischemic heart disease study, we identified patients with complex SCAD. Rates of ad-hoc PCI and documented heart team discussion were reported stratified by guideline recommended mode of revascularization. Completeness of revascularization was assessed by an angiographic core laboratory using residual SS (rSS) ≤ 8 and SYNTAX Revascularization Index (SRI) ≥ 70{\%}. Among 336 PCI patients with SCAD, 182 (54.2{\%}) had complex coronary disease and 152 underwent ad-hoc PCI (83.5{\%}). Patients for whom surgery was the recommended revascularization option (9.3{\%}) had a significantly and substantial higher rate of incomplete revascularization than patients for whom either mode of revascularization or PCI was recommended (61.3{\%} vs 23.6{\%} with rSS > 8, p < 0.001 and 77.4{\%} vs 44.6{\%} with SRI < 70{\%}, p < 0.001). Patients with complex SCAD receiving percutaneous myocardial revascularization when surgery was recommended have substantially incomplete myocardial revascularization. These data support multidisciplinary decision-making in these patients and suggest considering anticipated completeness when deciding mode of coronary revascularization.",
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AU - Lettieri, Corrado

AU - Bettari, Luca

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