The Study Of Outcomes Of Coronary Artery Disease Patients Revascularization Completely And Incompletely Referred By Anatomy And Pathophysiology

BackgroundThe coronary artery disease (CAD) is one of the most serious diseases in our country. The major treatments of it are the optimal medical therapy (OMT) and the revascularization, and the revascularization is composed by percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). No matter PCI or CABG, the therapy could possibly lead to incomplete revascularization to some extent. It is mainly because of the impact of serious vessel stenosis, numerous complications, or bad physical conditions, etc.For decades, lots of clinical studies focused on the comparison of complete revascularization (CR) and incomplete revascularization (IR). Some studies show that CR could lead to the outcome better than IR, while some others show that they have the similar effect. Though there is the meta-analysis trying to merge the results of studies to conduct a general conclusion, the significant heterogeneities among them have weakened the strength of it. Moreover, numerous studies have confirmed that the comparisons between CR and IR could not be concluded simply by just one word.On the other side, because the bad relationship between coronary lesions and myocardial ischemia, which could confuse the cardiologists by the long sequential lesions or wide range of collateral circulation, the revascularization guided by coronary angiography (CAG) needs improvements and innovations seriously.There are studies using fractional flow reserve (FFR) and single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) to do with CAD. The value of FFR has been confirmed by FAME and FAME 2 trials, and FFR has been recommended by guidelines in recent years. The value of SPECT-MPI has also been confirmed by clinical studies, and it has been demonstrated that the outcomes of CAD patients guided by myocardial ischemia are better than those by CAG. The resident of myocardial ischemia after revascularization also is the risk factor of CAD patient’s prognosis.However, because of the widely existing of IR, the great differences among the studies of CR and IR according to CAG, and the absence of study about CR and IR according to myocardial ischemia, it is important and necessary to conduct the research by the reference of SPECT-MPI, in order to find out the clinical value of it as the guidance of CR.Objectives1. To compare the clinical outcome about incomplete revascularization and complete revascularization in the CAD therapy.2. To evaluate in a retrospective analysis the impact of IR by CAG criteria vs. IR by stress radionuclide MPI criteria on long-term cardiac outcomes.3. To compare the long term outcomes among CR, IR, and MPT, to define the new concepts of complete revascularization, and further to evaluate the impact of different extent of myocardial ischemia on the prognoses of CAD patients by different revascularization strategies.Methods1. Articles were searched from MEDLINE and major international cardiology conferences. Outcomes of "All-Cause Death (ACD)" and "Cardiac Death (CD)" from individual studies were pooled to calculate relative risks (RRs) and Weighted Mean Difference (WMD) with 95% confidence intervals (CI). Baseline factors as age, diabetes mellitus (DM), hypertension (HTN) and SYNTAX Score were also recorded and analyzed.2. We performed a retrospective analysis of 170 patients with MPI ischemia and PCI. The primary endpoint was all-cause mortality at a mean follow-up of 47±21 months; and the secondary end point was the composite of deaths, nonfatal myocardial infarctions and repeat revascularizations (MACE). The coronary revascularization was defined as CR or IR as judged by CAG criteria and by MPI ischemia matched with CAG criteria.3. Two hundred and eighty-six consecutive patients with abnormal angiography and myocardial ischemia were consecutively followed for 45±21 months. Patients were divided into CR, IR and OMT three groups, or into two subgroups by 10% ischemic myocardium. Death and MACE were defined as endpoints.Results1. Twenty-six articles were enrolled in our study eventually. The mortality of IR group was significantly higher than the CR group [RR 1.43; 95%CI (1.28,1.59); P< 0.001]. The patients treated by PCI incompletely had the rate of all-cause death higher than those treated completely [RR 1.53; 95% CI (1.31,1.79); P= 0.02]. The same trend could be found in the patients treated by CABG, which showed that the IR group had higher rate of all-cause death than the CR group [RR 1.31; 95% CI (1.12,1.52); P = 0.002]. And the IR group also had the higher rate of cardiac death compared with the CR group [RR2.12; 95% CI (1.72,2.67); P= 0.012].2. Nighty-two patients (54%) had IR by CAG criteria (IR-CAG) and 84 (49%) had IR by MPI criteria (IR-MPI). Mortality and MACE were lower in patients with CR-MPI than with IR-MPI (log rank P= 0.048, and log rank P= 0.025). Survival of patients with CR-CAG and IR-CAG was not different (log rank P= 0.081). Patients with both IR-MPI and IR-CAG had the worst survival whereas patients with CR-MPI and CR-CAG had the best survival (log rank P= 0.047). By multivariate analysis, "IR-MPI×IR-CAG" was an independent predictor of death (P= 0.025).3. There was no difference between revascularization and OMT (survival:log rank P= 0.158). CR was associated with outcomes better than IR and OMT (survival: log rank P= 0.019, MACE-free survival:log rank P< 0.001). Patients with more than 10% ischemic myocardium showed differences that CR had outcomes better than IR and OMT (survival:log rank P= 0.034, MACE-free survival:log rank P< 0.001). Cox regression analysis revealed SDS and IR-MPI as negative predictors for outcomes.ConclusionsThe IR patients referred by SPECT-MPI always had higher rate of death and MACE, compared with the CR patients. The IR patients referred by both coronary angiography and SPECT-MPI had the highest possibility to death and MACE, while the CR y angiography and SPECT-MPI had the lowest rate of cardiac events. Moreover, patients with revascularization always had outcomes better than patients with medicine only. The opportunity was relate to the patients of severe ischemia (more than 10% myocardial ischemia). And there was no significant difference between patients with incomplete revascularization and medicine therapy only.Our study has demonstrated the clinical value of complete revascularization, and proposed the new idea of coronary artery disease therapy:"complete, incomplete revascularization or medicine therapy only" to "which degree of revascularization". It would be very important to the coronary artery disease therapy.