Impact Of Percutaneous Coronary Intervention On The Prognosis Of Patients With Chronic Total Occlusion And Analysis Of Influence Factors Of The Prognostic Outcome

Part 1 Impact of percutaneous coronary intervention on the prognosis of patients with chronic total occlusionBackgrounds: Chronic total occlusion(CTO)is a common coronary lesion subtype with an incidence rate of about 30% in patients with coronary heart disease.CTO lesion makes artery lumen occlusive,which cause myocardial ischemia in the distal dominating area,leading to refractory angina pectoris,impaired quality of life,and increased adverse cardiovascular events,as seriously threaten the patients’ life.Medication treatment alone is limited to improve the prognosis of these patients,and target vessel revascularization may be of great necessity.Percutaneous coronary intervention(PCI)is considered as one of the main measures to achieve revascularization.However,CTO PCI was always regarded as the last fortress of intervention,as great challenge could be encountered during the procedure,and amount of money could be consumed,consequently leading to huge burden for the family and community.At the same time,whether PCI can improve the prognosis is still controversial.The 2018 ESC/EACTS guidelines on myocardial revascularization recommended CTO PCI as a measure of class Ⅱa,while the 2021ACC/AHA/SCAI guidelines as Ⅱb.Conclusively,it is necessary to evaluate the impact CTO PCI on the prognosis of patients with CTO.Objectives: We aimed to explore outcomes of patients with CTO,and detect the impact of PCI on the prognosis of the population in the real world,and consequently analyze the potential influencing factors affecting the outcome,contributing to an improved patients management and outcome.Methods: As a retrospective cohort study,a total of 909 consecutive patients diagnosed as CTO following the CAG and conforming to the inclusion criteria in the Department of Cardiology of the First Affiliated Hospital of Air Force Military Medical University from January 2018 to December 2020 were included.They were divided into PCI + medication group(n=793)and medication group(n=116),and all patients were managed with prescription drug following guidelines.Information about clinical characteristics,coronary angiography characteristics,and baseline health status were collected,and the differences in prognostic outcomes between the two groups were followed up and evaluated.Primary endpoint was major adverse cardiovascular event(MACE),a composite event of all cause death,myocardial infarction,and symptom-driven rehospitalization.While secondary endpoints contained individual event included in MACE,health status related to angina(SAQ),and quality of life(SF-12).The difference in clinical characteristics,coronary angiography characteristics,and baseline health status was adjusted using propensity score matching(PSM)with a 1:1 ratio as a result of significant difference in some key variables between the two groups,and multivariate analysis of endpoint events was conducted to verify the impact of CTO PCI on the prognosis and explore the potential influencing factors.Results: Amount of 909 patients were enrolled in the study cohort,with 793 of them divided into PCI + medication group,and the other 116 into medication group.The median follow-up time was 30(21,38)months,and 880 patients(96.8%)completed the follow up,with 767 patients included in the PCI + medication group and the other 113 in the medication group.1.For the baseline characteristics,mean age for all patient were 61±11 years old,and86.6% of them were male.In comparing with patients in PCI + medication group,those in medication group were older,less of male,more proportion of NYHA grade of 3 or 4 class,and they also had a lower hemoglobin,lower platelet and higher NT-pro BNP,a lower proportion of prescription drug of aspirin,P2Y12 inhibitors,ticagrelor,and statins,with a smaller reference vessel diameter,longer lesion length,and a higher proportion of left coronary artery dominance and absence of collateral circulation.All the variables above showed a significant difference between the two groups(all P<0.05).After PSM,no significant difference in baseline characteristics between the two groups was detected,with 103 cases in each group(all P>0.05).2.The incidence of MACE(6.2% vs.25.0%,P<0.001),all cause death(3.7%vs.12.9%,P<0.001),and symptom-driven rehospitalization(1.3% vs.11.2%,P<0.001)was lower in PCI +medication group than in medication group,while the median score of all dimensions of SAQ and SF-12 were higher in the PCI +medication group(all P<0.05).After PSM,the risk of MACE(6.8% vs.25.2%;HR: 0.266;95%CI: 0.115-0.616;P<0.001),all cause death(4.9% vs.13.6%;HR: 0.354;95%CI: 0.126-0.992;P=0.039)and symptom-driven rehospitalization(1.0% vs.11.7%;HR: 0.083;95%CI: 0.011-0.638;P=0.002)could be reduced by PCI,while the median score of all dimensions of SAQ and SF-12 were also higher in the PCI + medication group(all P<0.05).3.The results of multivariate analysis of patients before PSM showed that PCI was the independent predictor of MACE(HR: 0.401;95%CI: 0.235-0.684;P=0.001),all cause death(HR: 0.469;95%CI: 0.222-0.989;P=0.047),and symptom-driven rehospitalization(HR:0.235;95%CI: 0.095-0.582;P=0.002)for CTO patients.Meanwhile,decreased hemoglobin(HR: 0.301;HR: 0.170-0.534;P<0.001),LVEF≤40%(HR: 2.954;95%CI:1.597-5.466;P<0.001),lesion in LM(HR: 2.379;95%CI: 1.257-4.503;P=0.008),absence of CC(HR: 2.295;95%CI: 1.213-4.344;P=0.011),and aspirin(HR: 2.295;95%CI: 1.213-4.344;P=0.011)were significantly associated with MACE,and ticagrelor(HR: 0.364;95%CI: 0.138-0.957;P=0.040)was significantly associated with symptom-driven rehospitalization.The results of multivariate analysis of patients after PSM showed that PCI was also the independent predictor of MACE(HR: 0.304;95%CI:0.127-0.727;P=0.007),all cause death(HR: 0.326;95%CI: 0.112-0.955;P=0.041),and symptom-driven rehospitalization(HR: 0.083;95%CI: 0.010-0.705;P=0.023)for CTO patients,and the other influencing factors were consistent with the results of multivariate analysis of patients before PSM.Conclusions: As compared with CTO patients received medication treatment,those who underwent PCI + medication took a lower risk of MACE,all cause death,and symptom-driven rehospitalization within 2.5 years after the procedure,with improved angina-related health status and quality of life.Decreased hemoglobin,LVEF≤40%,lesion in LM,absence of CC,and dual antiplatelet therapy were significantly associated with the prognosis of the CTO patients.Part 2 Analysis of prognostic factors of patients with chronic total occlusion treated by percutaneous coronary interventionBackground: In recent years,with great development in CTO PCI,more and more patients were founded to receive PCI.Many studies have confirmed the improved prognosis of this population underwent PCI,consistently with the conclusion in the former part of this study.However,CTO is one of the lesions hinting severe coronary heart disease,and many clinical comorbidities could be founded within these patients.Therefore,for the patients underwent CTO PCI,the influencing factors on prognosis were underestimated and controversial,especially for the procedure outcome.Therefore,exploration of prognostic factors in this population is great helpful for recognizing the severe status damaging health and making management easier,contributing to a better benefit for the population.Objectives: We aimed to examine predictors for the prognosis of patients underwent CTO PCI who were included in the PCI + medication group in Part one,as to make the procedure,patient management,and prognosis outcome improved.Methods: We described the clinical characteristics,coronary angiography characteristics,and procedure results of patients underwent CTO PCI(n=793),a component group in Part one,with a consequent multivariate analysis being conducted.The primary endpoint was MACE,a composite event of all cause death,myocardial infarction,and symptom-driven rehospitalization,and secondary endpoints were target vessel revascularization(TVR)and difference value of quality of life(SF-12).Multivariate analyses of MACE and TVR were performed with Cox regression model,and multivariate analyses of difference value of quality of life(SF-12)were performed with multiple linear regression model.Results: Of 793 patients underwent PCI enrolled in this part,767 patients(96.7%)completed the follow up,the median follow-up time was 30(21,39)months.MACE occurred in 49 patients(6.4%)and 52 patients(6.8%)received TVR.The mean difference value of physical component score and mental component score of SF-12 was 8±11 and5±11,respectively.1.Multivariate analysis of MACE showed that the absence of collateral circulation(HR: 2.025;95%CI: 1.131-3.626;P=0.018),residual SYNTAX score ≥12(HR: 2.436;95%CI: 1.384-4.287;P=0.002),in-hospital complications(HR: 2.892;95%CI:1.222-6.845;P=0.016)were risk factors,while prescription aspirin was a protective factor(HR: 0.309;95%CI: 0.138-0.692;P=0.004).DART showed no significant association with MACE.2.Multivariate analysis of TVR showed that chronic pulmonary disease(HR: 2.755;95%CI: 1.170-6.487;P=0.020),in-stent restenosis(HR: 3.975;95%CI: 1.862-8.484;P<0.001),ADR technique(HR: 2.396;95%CI: 1.216-4.723;P=0.012),procedure with operation time ≥ 3 hours(HR: 3.088;95%CI: 1.420-6.712;P=0.004)were risk factors,while recanalized LAD-CTO(HR: 0.379;95%CI: 0.193-0.742;P=0.005)and prescription aspirin(HR: 0.327;95%CI: 0.137-0.778;P=0.011)were protective factors.Stent length showed no significant association with TVR.3.Multiple linear regression of difference value of physical component score of SF-12 showed that increasing age(B=-0.087;β=-0.087;P=0.007)was the negative factor for physical improvement,while e GFR(B=0.011;β=0.096;P=0.003),PLT(B=0.013;β=0.080;P=0.013),and difference value of the summary score of SAQ(B=0.320;β=0.448;P<0.001)were positive factors.4.Multiple linear regression of difference value of the mental component score of SF-12 showed that increasing age(B=-0.077;β=-0.075;P=0.033)was the negative factor for mental improvement,while difference value of the summary score of SAQ(B=0.147;β=0.200;P<0.001)was positive factor.Conclusions: For CTO patients treated with PCI,absence of collateral circulation,residual SYNTAX score≥12,and in-hospital complications were the risk factors,and dual antiplatelet therapy was the protective factor for MACE.Chronic pulmonary disease,in-stent restenosis,ADR technique,and procedure with operation time≥3 hours were the risk factors,and recanalized LAD-CTO and prescription aspirin were the protective factors for TVR.The increasing age and a significant decrease in e GFR and platelet were associated with a poor improvement of quality of life,and increasing SAQ summary score was associated with an improved quality of life.