Early Revascularization More Effective than Conservative Approach in Patients with High-Risk Cardiac Anatomy

Kevin Bainey, MD

A new observational study is challenging the results of the ISCHEMIA trial after returning results suggests an invasive approach may be more effective for patient patients with anatomically high‐risk stable ischemic heart disease.

While ISCHEMIA concluded an early invasive approach did not provide substantial benefit in patients with stable ischemic heart disease, investigators noted the study did not address the effect of left main disease and high-risk coronary anatomy, which was the aim of the current study.

"What our results are saying is that medical management is important, but there might be a small group that would benefit from revascularization, and we need to find ways to identify that group of patients," said lead investigator Kevin Bainey, MD, director of the Adult Cardiac Catheterization and Interventional Cardiology Laboratory and the Interventional Cardiology Fellowship Program, in a statement. "The main message I want clinicians to know is that it's important to know the anatomy.”

To fill the apparent gap in knowledge related to effectiveness of optimal medical therapy compared to early invasive intervention in patients at a high anatomical risk coronary anatomy, Bainey and a team of colleagues designed their current study as an observational analysis using data from the APPROACH registry. From this cohort, investigators identified 9016 patients with stable ischemic heart disease and high-risk coronary anatomy.

For inclusion in the current study, patients were required to have 3 vessel disease with 70% or greater stenosis in all 3 epicardial vessels or left main disease with 50% or greater stenosis. Investigators noted these patients were all treated between April 1, 2002 and March 31, 2016. Investigators also created subgroups of interest for angiographic risk, which were defined as 3 vessel disease with 1 vessel stenosis of 95% or greater, 3 vessel disease with proximal left anterior descending coronary artery (pLAD) with 70% or greater stenosis, 3 vessel disease with pLAD and 95% or greater stenosis, left main disease with 50% or greater stenosis, and severe left main with 70% or greater stenosis.

For the purpose of analysis, investigators established a primary composite outcome of all-cause death or myocardial infarction in patients receiving revascularization versus conservative management with optimal medical therapy.

Upon analysis, investigators found 61% (n=5487) of patients received revascularization with either coronary artery bypass graft surgery (n=3312) or percutaneous coronary intervention (n=2175) and 39% (n=3529) were managed conservatively. Results indicated undergoing coronary revascularization was associated with a reduction in the study’s primary composite outcomewhen compared with section for conservative management (Inverse Probability Weighted hazard ratio [IPW‐HR]; 0.62; 95% CI, 0.58-0.66; P <0.001; IPW‐HR 0.57; 95% CI 0.53-0.61; P <.001, respectively). Further analysis suggested a similar risk reduction occurred when examining percutaneous coronary intervention (IPW‐HR, 0.64; 95% CI, 0.59-0.70, P <.001) and coronary artery bypass grafting (IPW‐HR, 0.61; 95% CI, 0.57-0.66; P <.001).

"We strongly believe coronary anatomy is an important prognostic indicator of health outcomes," added Bainey. “In a patient who has a higher-risk stress test and is showing symptoms, we think it's valuable to perform a coronary angiogram to get a complete picture, rather than just managing them with medications."

This study, “Long‐Term Clinical Outcomes Following Revascularization in High‐Risk Coronary Anatomy Patients With Stable Ischemic Heart Disease,” was published in the Journal of the American Heart Association.