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Research Article | Open Access

Long-term outcome of percutaneous or surgical revascularization with and without prior stroke in patients with three-vessel disease

Na XU, Ce ZHANG, Lin JIANG, Jing-Jing XU, Ru LIU, Ying SONG, Xue-Yan ZHAO, Lian-Jun XU, Run-Lin GAO, Bo XU, Jin-Qing YUAN(), Lei SONG()
Center for Coronary Heart Disease, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Abstract

OBJECTIVE

To determine whether high-risk patients with three-vessel disease (TVD) with and without prior stroke preferentially benefit from three strategies [percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical therapy (MT)].

METHODS

A total of 8943 patients with TVD were included in the study. Patients enrolled were stratified into two categories according to the presence or absence of prior stroke history. The primary endpoint was all-cause death. Secondary endpoints included stroke and major adverse cardiac and cerebrovascular event (MACCE), a composite of death, myocardial infarction (MI), unplanned revascularization and stroke.

RESULTS

Prior stroke was present in 888 patients (9.9%). These patients were older and had higher rates of comorbidities. During a median follow-up of 7.5 years, patients with prior stroke were strongly associated with increased risks of all-cause death, cardiac death, stroke and MACCE, even after adjusting for confounding variables and results been consistent across either treatment subgroup (PCI, CABG and MT) (all adjusted P < 0.01). Notably, there was a significant interaction between prior stroke history and treatment strategies. Revascularization strategy (PCI or CABG) was associated with a lower incidence of all-cause death and MACCE compared with MT alone, and favorable rates of MACCE, MI and unplanned revascularization in the CABG group compared with the PCI group, but with similar rate of all-cause death regardless of prior stroke history. The prevalence of stroke was significantly higher after CABG when compared with PCI or MT in no prior stroke patients [hazard ratio (HR) = 1.429, 95% CI: 1.132–1.805 for CABG vs. MT; HR = 1.703, 95% CI: 1.371–2.116 for CABG vs. PCI].

CONCLUSIONS

Patients with TVD and prior stroke have poor clinical outcomes. It is essential to balance benefit and risk when determining the optimal treatment strategy for TVD with and without prior stroke.

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Journal of Geriatric Cardiology
Volume 19 Issue 8,
August 2022
Pages 583-593
DOI: 10.11909/j.issn.1671-5411.2022.08.001
Cite this article:
XU N, ZHANG C, JIANG L, et al. Long-term outcome of percutaneous or surgical revascularization with and without prior stroke in patients with three-vessel disease. Journal of Geriatric Cardiology, 2022, 19(8): 583-593. https://doi.org/10.11909/j.issn.1671-5411.2022.08.001
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Baseline clinical, angiographic and medications in the prior stroke and no prior stroke groups.

VariablesTotal population (n = 8943)Propensity-matched patients (n = 1694)
Prior stroke (n = 888)No prior stroke (n = 8055)P-valuePrior stroke (n = 847)No prior stroke (n = 847)P-value
Data are presented as means ± SD or n (%).
Age, yrs 64.32 ± 8.68 60.70 ± 10.04 < 0.001 64.23 ± 8.65 62.71 ± 10.04 0.001
Male 699 (78.7%) 6423 (79.7%) 0.472 665 (78.5%) 671 (79.2%) 0.721
Body mass index, kg/m2 25.73 ± 3.06 25.84 ± 3.06 0.342 25.75 ± 3.06 25.79 ± 2.98 0.817
Risk factors
　Diabetes mellitus 366 (41.2%) 2751 (34.2%) < 0.001 352 (41.6%) 334 (39.4%) 0.373
　Hypertension 721 (81.2%) 5334 (66.2%) < 0.001 688 (81.2%) 640 (75.6%) 0.005
　Hypercholesterolemia 513 (57.8%) 4492 (55.8%) 0.254 487 (57.5%) 467 (55.1%) 0.327
　Current smoker 508 (57.2%) 473 (55.5%) 0.340 481 (56.8%) 441 (52.1%) 0.051
　Family history of coronary artery disease 244 (27.5%) 2380 (28.9%) 0.366 239 (28.2%) 237 (28.0%) 0.914
　Peripheral arterial disease 145 (16.3%) 545 (6.8%) < 0.001 144 (17.0%) 131 (15.5%) 0.392
　Chronic obstructive pulmonary disease 18 (2.0%) 82 (1.0%) 0.007 15 (1.8%) 11 (1.3%) 0.429
　Bleeding 27 (3.0%) 118 (1.5%) < 0.001 27 (3.2%) 29 (3.4%) 0.786
Clinical history
　Previous myocardial infarction 315 (35.5%) 2869 (35.6%) 0.932 293 (34.6%) 291 (34.4%) 0.919
　Previous percutaneous coronary intervention 98 (11.0%) 1033 (12.8%) 0.128 87 (10.3%) 85 (10.0%) 0.872
　Previous coronary artery bypass grafting 28 (3.2%) 279 (3.5%) 0.630 21 (2.5%) 23 (2.7%) 0.624
Left ventricular ejection fraction, % 57.61 ± 10.16 58.31 ± 9.79 0.065 57.56 ± 10.26 58.10 ± 9.74 0.294
Creatinine clearance rate, mL/min 78.16 ± 23.62 86.26 ± 26.95 < 0.001 78.19 ± 23.70 81.63 ± 25.80 0.004
Glycosylated hemoglobin,% 6.57 ± 1.34 6.51 ± 1.43 0.326 6.57 ± 1.35 6.49 ± 1.33 0.346
High-density lipoprotein cholesterol, mmol/L 1.05 ± 0.33 1.04 ± 0.25 0.266 1.05 ± 0.32 1.05 ± 0.26 0.874
Low-density lipoprotein cholesterol, mmol/L 2.48 ± 0.79 2.56 ± 0.91 0.011 2.49 ± 0.80 2.54 ± 0.82 0.138
Triglyceride, mmol/L 2.09 ± 11.59 1.78 ± 1.07 0.021 1.71 ± 0.92 1.75 ± 1.07 0.407
Total cholesterol, mmol/L 4.50 ± 1.07 4.60 ± 1.06 0.008 4.51 ± 1.07 4.59 ± 1.07 0.116
Chronic kidney disease 203 (22.9%) 1244 (15.4%) < 0.001 191 (22.6%) 161 (19.0%) 0.072
Thrombocytopenia 21 (2.4%) 126 (1.6%) 0.075 20 (2.4%) 16 (1.9%) 0.500
Anemia 258 (29.1%) 1741 (21.6%) < 0.001 249 (29.4%) 231 (27.3%) 0.332
Presentation 0.001 0.498
　Acute coronary syndrome 618 (69.6%) 5145 (63.9%) 584 (68.9%) 571 (67.4%)
　Stable angina 270 (30.4%) 2910 (36.1%) 263 (31.1%) 276 (32.6%)
Left main involvement 217 (24.4%) 1846 (22.9%) 0.383 212 (25.0%) 206 (24.3%) 0.732
STNYAX score < 0.001 0.150
　≤ 22 307 (34.8%) 3252 (40.5%) 284 (33.5%) 296 (34.9%)
　23–32 328 (37.1%) 2962 (36.9%) 323 (38.1%) 346 (40.9%)
　≥ 33 248 (28.1%) 1808 (22.5%) 240 (28.3%) 205 (24.2%)
SYNTAX score 26.69 ± 10.44 25.10 ± 11.26 < 0.001 27.23 ± 9.72 26.41 ± 9.70 0.081
SSII for percutaneous coronary intervention 33.55 ± 9.72 29.53 ± 9.06 < 0.001 33.59 ± 9.72 32.06 ± 9.87 0.001
SSII for coronary artery bypass grafting 27.47 ± 9.96 23.04 ± 9.64 < 0.001 27.51 ± 9.97 25.93 ± 10.45 0.002
Treatment strategy < 0.001 0.276
　Medical therapy 285 (32.1%) 2136 (26.5%) 310 (36.6%) 341 (40.3%)
　Percutaneous coronary intervention 328 (36.9%) 3497 (43.4%) 271 (32.0%) 262 (30.9%)
　Coronary artery bypass grafting 275 (31.0%) 2422 (30.1%) 266 (31.4%) 244 (28.8%)
Anticoagulant in hospital
　Low-molecular-weight heparin 611 (68.8%) 5276 (65.5%) 0.049 588 (69.4%) 573 (67.7%) 0.433
　ARIXTRA 5 (0.6%) 22 (0.3%) 0.135 5 (0.6%) 1 (0.1%) 0.102
　Xa inhibitor 461 (51.9%) 3839 (47.7%) 0.016 442 (52.2%) 410 (48.4%) 0.120
　IIbIIIa inhibitor 7 (0.8%) 88 (1.1%) 0.401 7 (0.8%) 5 (0.6%) 0.562
Medication at discharge
　Aspirin 840 (94.6%) 7700 (95.6%) 0.174 804 (94.9%) 800 (94.5%) 0.665
　Clopidorel 451 (50.8%) 4219 (52.4%) 0.368 430 (50.8%) 436 (51.5%) 0.771
　Angiotensin-converting enzyme inhibitors/ 　Angiotensin II receptor blockers 487 (54.8%) 4124 (51.2%) 0.040 464 (54.8%) 448 (52.9%) 0.436
Statin 588 (66.2%) 5394 (67.0%) 0.653 557 (65.8%) 554 (65.4%) 0.878
　Beta-blockers 782 (88.1%) 7076 (87.8%) 0.851 748 (88.3%) 747 (88.2%) 0.940
　Calcium antagonist 352 (39.6%) 2877 (35.7%) 0.021 331 (39.1%) 336 (39.7%) 0.804
　Nitrate 832 (93.7%) 7456 (92.6%) 0.220 798 (94.2%) 778 (93.0%) 0.320

Unadjusted and adjusted primary and secondary outcomes according to prior stroke in all patients and in the propensity score-matched cohort.

OutcomeTotal populationPropensity-matched patients
Number of patients with eventAdjusted HR (95% CI)*P-valueNumber of patients with eventAdjusted HR (95% CI)*P-value
CI: confidence interval; HR: hazard ratio. *Refers to adjust for baseline variables, including age, sex, hypertension, diabetes mellitus, bleeding history, anemia, chronic kidney disease, total cholesterol, low-density lipoprotein cholesterol, left main involvement, left ventricular ejection fraction, SYNTAX score and treatment strategy.
All-cause death
　Prior stroke 209 (23.5%) 1.472 (1.255–1.727) < 0.001 198 (23.4%) 1.578 (1.273–1.956) < 0.001
　No prior stroke 1156 (14.4%) Reference 145 (17.1%) Reference
Cardiac death
　Prior stroke 115 (13.0%) 1.581 (1.274–1.962) < 0.001 111 (13.1%) 1.680 (1.254–2.252) 0.001
　No prior stroke 574 (7.1%) Reference 76 (9.0%) Reference
Major adverse cardiac and cerebrovascular event
　Prior stroke 348 (39.2%) 1.281 (1.135–1.447) < 0.001 335 (39.6%) 1.402 (1.195–1.644) < 0.001
　No prior stroke 2482 (30.8%) Reference 277 (32.7%) Reference
Myocardial infarction
　Prior stroke 45 (5.1%) 1.064 (0.762–1.484) 0.717 45 (5.3%) 0.909 (0.614–1.345) 0.634
　No prior stroke 470 (5.8%) Reference 57 (6.7%) Reference
Stroke
　Prior stroke 85 (9.6%) 1.396 (1.090–1.788) 0.008 83 (9.8%) 1.482 (1.072–2.049) 0.017
　No prior stroke 557 (6.9%) Reference 66 (7.8%) Reference
Unplanned revascularization
　Prior stroke 62 (7.0%) 1.022 (0.781–1.338) 0.873 62 (7.3%) 1.051 (0.738–1.496) 0.784
　No prior stroke 698 (8.7%) Reference 61 (7.2%) Reference

Risks of primary and secondary outcomes according to prior stroke and three strategies in all patients.

OutcomeNumber of patients with eventAdjusted HR (95% CI)*
PCICABGMTPCI vs. MTCABG vs. MTCABG vs. PCI
CABG: coronary artery bypass grafting; CI: confidence interval; HR: hazard ratio; MT: medical therapy; PCI: percutaneous coronary intervention. *Refers to adjust for baseline variables, including age, sex, hypertension, diabetes mellitus, bleeding history, anemia, chronic kidney disease, total cholesterol, low-density lipoprotein cholesterol, left main involvement, left ventricular ejection fraction, SYNTAX score and treatment strategy.
All-cause death
　Prior stroke 69 (21.0%) 44 (16.0%) 96 (33.7%) 0.706 (0.488–1.021) 0.509 (0.336–0.771) 0.721 (0.459–1.132)
　No prior stroke 369 (10.6%) 241 (10.0%) 546 (25.6%) 0.484 (0.416–0.564) 0.409 (0.347–0.481) 0.844 (0.703–1.012)
Major adverse cardiac and cerebrovascular event
　Prior stroke 132 (40.2%) 83 (30.2%) 133 (46.7%) 0.843 (0.635–1.119) 0.551 (0.404–0.751) 0.653 (0.473–0.902)
　No prior stroke 1079 (30.9%) 539 (22.3%) 864 (40.4%) 0.762 (0.688–0.843) 0.503 (0.448–0.564) 0.660 (0.588–0.740)
Stroke
　Prior stroke 35 (10.7%) 30 (10.9%) 20 (7.0%) 0.996 (0.541–1.831) 1.169 (0.634–2.156) 1.174 (0.660–2.089)
　No prior stroke 202 (5.8%) 222 (9.2%) 133 (6.2%) 0.839 (0.656–1.072) 1.429 (1.132–1.805) 1.703 (1.371–2.116)
Myocardial infarction
　Prior stroke 24 (7.3%) 6 (2.2%) 15 (5.3%) 1.059 (0.497–2.256) 0.359 (0.134–0.965) 0.339 (0.126–0.911)
　No prior stroke 194 (8.4%) 61 (2.5%) 115 (5.4%) 1.374 (0.975–1.756) 0.440 (0.317–0.612) 0.320 (0.238–0.432)
Unplanned revascularazation
　Prior stroke 31 (9.5%) 10 (3.6%) 21 (7.4%) 1.071 (0.581–1.971) 0.363 (0.166–0.794) 0.339 (0.159–0.729)
　No prior stroke 441 (12.6%) 74 (3.1%) 183 (8.6%) 1.172 (0.968–1.419) 0.304 (0.229–0.404) 0.259 (0.199–0.338)