The Impact Of Release Of Clinical Practice Guidelines On Therapeutic Strategies And Prognosis For Complex Coronary Artery Heart Disease

ObjectivesTo analyze the impact of Coronary Revascularization Practice Guidelines issuedby ACCF/AHA on revascularization strategy for patients with complex coronaryartery heart disease.MethodThe patients, who diagnosed with complex CAD, suggested to take PCI orCABG and underwent elective angiography examination between July2011andSeptember2012, were registered on a consecutive basis. All enrolled patients weredivided into two groups named Group A-pre guidelines (551patients, from July2011to15th November,2011) and Group B-post guidelines (1201patients, from16th November,2011to September2012) according to the release date of theGuidelines. The basic clinical conditions, coronary SYNTAX integral value and thetherapeutic strategies recommend by the doctors of those patients were recorded atthe same time. The baseline characteristics,"heart team"(surgical consultation), andrevascularization strategies between the two groups were compared together with thefollow-up about the incidence of main adverse cardiovascular and cerebrovascularevents(MACCE) through the ways of telephone inquiries and outpatient service, andthe analysis of the recommended revascularization strategies were proceeded with logistic multi-factor analysis. The risk factors associated with MACCE rate wereevaluated through cox regression analysis to analyze the therapeutic strategiesdoctor’s recommendation and the actual execution.ResultA total of1884patients were enrolled in our study and the following datarecords obtained by extraction and revascularization strategies proposed collection.There were22cases (1.2%) with ambiguity treatment that were removed from ourstudy, and1862cases (98.9%) with the recommends of the doctors.1. There were270patients (51.0%) suggested undergoing PCI, and281patients (49.0%) suggestedundergoing CABG before the release of the guideline. While, there were533patients(44.4%) suggested undergoing PCI, and230patients (41.7%) suggested undergoingCABG. There were230patients (41.7%) with cardiology and cardiac surgery expertconsultation before the release of the guideline compared with594patients (49.5)after that. The differences were statistically significantly (P<0.01). On the other hand,there were262patients (47.5%) underwent Ad Hoc PCI before the release comparedwith491patients (40.9%) after that, and the difference was statistically significant.However, there were19patients (6.6%) suggested undergoing PCI and270patients(93.4%) suggested undergoing CABG of all patients underwent electiverevascularization after angiography(N=999) before the release, compared that42patients (5.9%) with PCI and668patients (94.1%) with CABG after the release.There were230patients (79.6%) with cardiac surgical consultation before, comparedwith594patients (83.7%) with that after. The differences were not statisticallysignificant.2.1862patients were followed up one year after leaving hospital, inwhich5cases (0.2%) were lost and1857cases (98.8%) were retained. The patientsincluded587patients (31.5%) before the release of the guideline and1273patients(68.5%) after that. There were4cases with death,5cases with re-myocardialinfarction,13cases with recurrent stroke,91patients with repeat revascularization,and146cases with MACCE. The mortality rate and the rate of revascularizationbefore the release of the guideline were higher than those after that, while the difference was not statistically significant. And the difference between the rates ofre-myocardial infarction before and after the release also was non-significant. Thedifference between the rates of MACCE before and after the release was significant.3.Age, previous history of myocardial infarction, history of peripheral vascular disease,lesion type, left ventricular ejection fraction, SYNTAX score and released guidelinesare independent risk factors for the ratio of doctors recommend CABG according tothe multivariate logistic regression analysis in which the OR of the release of theguideline was1.31(95%CI1.04-1.68, P＜0.05). Age, previous history of myocardialinfarction, history of peripheral vascular disease, lesion type, left ventricular ejectionfraction, SYNTAX score and released guidelines are independent risk factors forcardiac surgical consultation ratio in which the OR of the release of the guideline was1.37(95%CI1.10-1.71, P＜0.05). Age, previous history of myocardial infarction,history of peripheral vascular disease, lesion type, left ventricular ejection fraction,SYNTAX score and released guidelines are independent risk factors for Ad Hoc PCIratio in which the OR of the release of the guideline was0.77(95%CI0.69-0.97, P＜0.05). All differences were statistically significant.4. Age, previous history ofmyocardial infarction, body mass index (BMI), lesion type, left ventricular ejectionfraction, SYNTAX score and guide released is an independent risk factor of MACCEaccording to COX regression analysis in which the OR value of the comparedincident rate of MACCE before and after the guideline release was1.62(95%CI1.16-2.78, P<0.05). The difference was statistically significant.ConclusionAfter the issue of the guidelines, the amount of CABG suggested by "heart team"and doctors increased significantly and the revascularization suggestions morecomplied with the guidelines.