| Part 1Impact of Previous Percutaneous Revascularization on Long-term Outcome of Repeat Coronary Intervention in Acute Coronary Syndrome PatientsBackgroundPercutaneous Coronary Intervention(PCI)is an essential revascularization therapy for Coronary atherosclerotic heart disease,especially for patients with acute coronary syndrome(ACS).PCI can alleviate ischemia,protect the myocardium,reduce mortality and improve the long-term prognosis of ACS patients.With the maturity of PCI technology and broaden of the clinical application,more patients received PCI therapy.However,for the progress of coronary artery atherosclerosis,occurrence of in-stent restenosis and stent thrombosis,patients with PCI history suffer unstable angina,acute myocardial infarction and even sudden death,often confront with revascularization,and PCI therapy is one of the most important means of revascularization.Repeat PCI for those patients are particular for a longer history of coronary heart disease,more severe coronary artery lesions and more complicated lesion types.Therefore,it’s important to discuss the repeat PCI therapy and prognosis in patients with prior PCI.And the impact of prior PCI on long-term outcomes for ACS patients undergoing repeat coronary intervention is still unknown.ObjectiveTo compare the efficiency,safty and long-term outcome in ACS patients undergoing PCI with or without previous PCI.MethodsAll consecutive ACS patients presenting for PCI between January,2013 and December,2013 in Fuwai hospital were included.Patients with prior Coronay Artery Bypass Grafting(CABG)were excluded.We evaluated 2 years clinical outcomes following PCI and compared patients with previous PCI and without previous PCI.The primary endpoint was all cause death.The secondary endpoint were cardiac death,major adverse cardiovascular and cerebrovascular events(MACCE),myocardial infarction,stroke,revascularization and stent thrombosis.These data were compared by t test and Pearson χ2 test.The PSM was used to balance the baseline disequilibrium.The cumulative survival curves for endpoint events were constructed using the Kaplan-Meier method,and were compared by the Log-rank test.Cox proportional regression model was used to assess the independent predictors of endpoint events.All P values were two-sided and P<0.05 was considered statistically significant.ResultsOf all 6194 consecutive ACS patients without prior CABG were encluded,1256(20.3%)had PCI history and 55(4.4%)had in-stent restenosis.Compared with paitent with prior PCI,patients with prior PCI were older(60 ± 10 vs.58 ± 10,p<0.001)and had more clinical risk factors(mellitus diabetes,hyperlipidemia,previous myocardial infarction and current smoking).Patients with prior PCI were presented with more acute ST-segement elevated myocardial infarction(25.7%vs.22.3%,p =0.012),left ventricular dysfunction(2.6%vs.0.9%,p<0.001)and renal dysfunction(43.9%vs.37.3%,p<0.001).Patients with PCI history were presented with more three vessel disease(44.9%vs.37.2%,p<0.001),total occlusion vessel(26.4%vs.17.4%,p<0.001),PTCA with drug balloon,IABP use and transfemoral access during process procedure,less procedure success(96.6%vs.97.8%,p = 0.02)and drug-eluting stent.At 2-years follow-up,6161(99.5%)patients completed 2 years follow up.At 2 years follow up,all cause death(2.3%vs.1.1%,p<0.01),cardiac death(1.7%vs.0.5%,p<0.001),myocardial infarction(2.7%vs.1.8%,p = 0.040) and major adverse cardiovascular and cerebrovascular events(MACCE)(13.9%vs.11.8%,p = 0.04)rates were significantly higher in previous PCI patients than in patients without PCI.After multivariable COX analysis,previous PCI was an independent predictor of all cause death(HR= 1.80,95%CI:1.12-2.90,p = 0.02)and cardiac death(HR = 2.27,95%CI:1.23-4.18,p = 0.01).However,after propensity score matched analyses(1226 pairs patients),previous PCI use was no longer an independent predictor of all cause death(HR =1.41,95%CI:0.81-2.47,p = 0.23)and cardiac death(HR = 1.40,95%CI:0.72-2.70,p = 0.32).Conclusions(1)In a large single population,patients with prior PCI often had more clinical risk factors.(2)At 2 years follow up,all cause death、cardiac death、myocardial infarction and MACCE rates were significantly higher in previous PCI patients than in patients without PCI.However,there were no significant difference in revascularization,stroke and stent thrombosis between the two groups.(3)After propensity score matched analyses,previous PCI use was no longer an independent predictor of all cause death and cardiac death.(4)Risk factors of previous PCI patients(such as older age,left ventricular dysfunction,previous stroke,mellitus diabetes and unsucessed PCI)were independent risk factors of long-term adverse prognosis.Part 2Impact of Previous Coronary Artery Bypass Grafting on Long-term Outcomes in Patients Undergoing Percutaneous Coronary InterventionBackgroundCoronary Artery Bypass Grafting(CABG)is a guideline recommended revascularization method for left main and three vessels disease,especial those patients with mellitus diabetes and left ventricular dysfunction.Despite of emphasis on secondary prevention,patients with prior CABG always suffer from ongoing atherosclerosis in naive coronary artery and grafting vessels.It was documented that about 10%vein grafting vessels occluded in one year after CABG,at mean time vein grafting vessels were degenerated at 2-5%per year.Due to ongoing atherosclerosis in naive coronary artery and grafting vessels,patients with prior CABG recurred angina pectoris,acute myocardial infarction and even sudden death.Those patients were confronted with revascularization.Revascularization by CABG were difficult in clinical practice for the anatomy changes of heart and coronary artery after CABG.And PCI was an optional for revascularization for those patients.However,for the change of coronary artery supply range and anatomy structure,PCI after CABG had special characteristics.Thus,it was very important to discuss the characteristics and prognosis of PCI revascularization after CABG.And the impact of prior CABG on long-term outcomes for patients undergoing repeat coronary intervention is still unknown.ObjectiveTo compare the efficiency,safety and long-term outcome in patients undergoing PCI revascularization with or without CABG.MethodsAll consecutive patients presenting for PCI between January and December,2013 in Fuwai hospital were prospectively included in this research.We evaluated 2-years clinical outcomes following PCI and compared patients with previous PCI and without previous PCI.The primary endpoint was all cause death.The secondary endpoint were cardiac death,main adverse cardiovascular and cerebrovascular events(MACCE),myocardial infarction,stroke,revascularization and stent thrombosis.The population was divided into two groups:prior CABG group and non-prior CABG group.These data were compared by t test and Pearson χ2 test.The PSM was used to balance the baseline disequilibrium.The cumulative survival curves for endpoint events were constructed using the Kaplan-Meier method,and were compared by the Log-rank test.Cox proportional regression model was used to assess the independent predictors of endpoint events.All P values were two-sided and P<0.05 was considered statistically significant.Results10724 consecutive patients were included.437(4.1%)had previously CABG history and 10287(95.9%)patients didn’t have prior CABG history.At baseline characteristics,prior CABG patients were older(61 ± 10 years vs.58 ± 10 years,P<0.001)and more often had mellitus diabetes(35.7%vs.30.0%,p = 0.012),hyperlipoidemia(73.9%vs.67.0%,p<0.01),previous myocardial infarction(31.1%vs.18.7%,p<0.001),previous PCI(61.6%vs.23.0%,p<0.001),cerebrovascular disease(7.1%vs.10.9%,p = 0.01),stable angina(40.5%vs.31.6%,p<0.001),left ventricular dysfunction(3.2%vs.1.1%,p<0.01)and renal dysfunction(50.8%vs.38.1%,p<0.001),compared to patients without previous CABG.251(57.4%) patients had vein grafting disease,6(1.4%)patients had artery grafting disease.Prior CABG patients had more left main(5.9%vs.2.4%,p<0.01),three vessel disease(73.0%vs.40.6%,p<0.001),occlusion and calcium disease.Only 18(31.0%)patients underwent PCI on grafting vessels.Compared to non-prior CABG group,prior CABG group had lower PCI success rate(95.4%vs.97.3%,p = 0.04),drug-eluting stent implantation,but had more trans-femoral PCI and use of intravascular ultrasound and intra-aortic balloon pump during procedure.10665(99.5%)patients accomplished 2 years follow up.At 2-years follow-up,cardiac death(1.8%vs.0.6%,p = 0.01),revascularization(11.2%vs.8.5%,p = 0.049)and MACCE(15.1%vs.12.0%,p = 0.049)rates following PCI in the CABG patients were significantly higher than in patients without CABG.However,all cause death(2.1%vs.1.2%,p = 0.11),myocardial infarction(2.3%vs.2.0%,p = 0.60),stent thrombosis(1.1%vs.0.6%,p = 0.19)and stroke(1.1%vs.1.4%,p = 0.70)were no significant different between the two groups.After multivariable COX analysis,previous CABG was an independent predictor of cardiac death(HR = 2.13,95%CI:1.02-4.46,p = 0.045)and revascularization(HR = 1.35,95%CI:1.01-1.81,p=0.04).However,after propensity score matched analyses(429 pairs),previous CABG use was no longer an independent predictor of cardiac mortality(HR = 0.97,95%CI:0.37-2.54,p = 0.95)and revascularization(HR= 1.74,95%CI:0.94-3.21,p= 0.75).Conclusion(1)In the large center of coronary heart disease in China,prior CABG patients often had more clinical risk factors;(2)Compared to non-prior CABG patients,prior CABG patients had more cardiac death,revascularization and MACCE,but all cause death,myocardial infarction,Stent thrombosis and stroke were no significant different between the two groups.(3)After propensity score matched analyses,previous CABG history was not an independent predictor of cardiac death and revascularization.(4)Risk factors of previous CABG patients(such as older age,left ventricular dysfunction and renal dysfunction)were independent risk factors of long-term adverse prognosis. |
PDF Full Text Request