Stuart J Head1, Bruno R da Costa2, Berend Beumer1, Giulio G Stefanini3, Fernando Alfonso4, Peter M Clemmensen5, Jean-Philippe Collet6, Jochen Cremer7, Volkmar Falk8, Gerasimos Filippatos9, Christian Hamm10, A Pieter Kappetein1, Adnan Kastrati11, Juhani Knuuti12, Philippe Kolh13, Ulf Landmesser14, Günther Laufer15, Franz-Josef Neumann16, Dimitrios J Richter17, Patrick Schauerte18, David P Taggart19, Lucia Torracca20, Marco Valgimigli21, William Wijns22, Adam Witkowski23, Stephan Windecker21, Peter Jüni24, Miguel Sousa-Uva25. 1. Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands. 2. Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland. 3. Department of Biomedical Sciences, Humanitas University, Rozzano-Milan, Italy. 4. Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain. 5. Department of Medicine, Nykoebing F Hospital, University of Southern Denmark, Odense, Denmark. 6. ACTION Study Group, Université Pierre et Marie Curie (UPMC-Paris 06), Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), Paris, France. 7. Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany. 8. Department of Cardiothoracic and Vascular Surgery, Klinik für Herz-Thorax-Gefässchirurgie, Deutsches Herzzentrum Berlin, Berlin, Germany. 9. Heart Failure Unit, Department of Cardiology, Athens University Hospital Attikon, Athens, Greece. 10. Department of Cardiology, Kerckhoff Heart and Thoraxenter, Bad Nauheim, Germany. 11. Department of Adult Cardiology, Deutsches Herzzentrum München, Technische Universität, Munich, Germany. 12. Turku PET Centre, University of Turku and Turku University Hospital, Turku, Finland. 13. Department of Cardiovascular Surgery, University Hospital of Liege, Liege, Belgium. 14. Department of Cardiology, Charité Berlin-University Medicine, Campus Benjamin Franklin and Berlin Institute of Health (BIH), Berlin, Germany. 15. Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria. 16. Division of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany. 17. Second Cardiac Department, Euroclinic Hospital, Athens, Greece. 18. Department of Cardiology, University Hospital Aachen RWTH, Aachen, Germany. 19. Department of Cardiovascular Surgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom. 20. Cardio Center, Humanitas Research Hospital, Rozzano-Milan, Italy. 21. Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland. 22. Cardiovascular Research Center, OLV Hospital Aalst, Aalst, Belgium. 23. Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland. 24. Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. 25. Department of Cardiac Surgery, Hospital Cruz Vermelha, Lisbon, Portugal.
Abstract
OBJECTIVES: The aim of the current study was to estimate adverse event rates while awaiting myocardial revascularization and review criteria for prioritizing patients. METHODS: A PubMed search was performed on 19 January 2015, to identify English-language, original, observational studies reporting adverse events while awaiting coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Rates of death, non-fatal myocardial infarction (MI) and emergency revascularization were calculated as occurrence rates per 1000 patient-weeks and pooled using random-effects models. RESULTS: The search yielded 1323 articles, of which 22 were included with 66 410 patients and 607 675 patient-weeks on the wait list. When awaiting CABG, rates per 1000 patient-weeks were 1.1 [95% confidence interval 0.9-1.3] for death, 1.0 [0.6-1.6] for non-fatal MI and 1.8 [0.8-4.1] for emergency revascularization. Subgroup analyses demonstrated consistent outcomes, and sensitivity analyses demonstrated comparable event rates with low heterogeneity. Higher urgency of revascularization was based primarily on angiographic complexity, angina severity, left ventricular dysfunction and symptoms on stress testing, and such patients with a semi-urgent status had a higher risk of death than patients awaiting elective revascularization (risk ratio at least 2.8). Individual studies identified angina severity and left ventricular dysfunction as most important predictors of death when awaiting CABG. Adverse rates per 1000 patient-weeks for patients awaiting PCI were 0.1 [95% confidence interval 0.0-0.4] for death, 0.4 [0.1-1.2] for non-fatal MI and 0.7 [0.4-1.4] for emergency revascularization but were based on only a few old studies. CONCLUSIONS: Rates of death, non-fatal MI and emergency revascularization when awaiting myocardial revascularization are infrequent but higher in specific patients. Countries that not yet have treatment recommendations related to waiting times should consider introducing a maximum to limit adverse events, particularly when awaiting CABG.
OBJECTIVES: The aim of the current study was to estimate adverse event rates while awaiting myocardial revascularization and review criteria for prioritizing patients. METHODS: A PubMed search was performed on 19 January 2015, to identify English-language, original, observational studies reporting adverse events while awaiting coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Rates of death, non-fatal myocardial infarction (MI) and emergency revascularization were calculated as occurrence rates per 1000 patient-weeks and pooled using random-effects models. RESULTS: The search yielded 1323 articles, of which 22 were included with 66 410 patients and 607 675 patient-weeks on the wait list. When awaiting CABG, rates per 1000 patient-weeks were 1.1 [95% confidence interval 0.9-1.3] for death, 1.0 [0.6-1.6] for non-fatal MI and 1.8 [0.8-4.1] for emergency revascularization. Subgroup analyses demonstrated consistent outcomes, and sensitivity analyses demonstrated comparable event rates with low heterogeneity. Higher urgency of revascularization was based primarily on angiographic complexity, angina severity, left ventricular dysfunction and symptoms on stress testing, and such patients with a semi-urgent status had a higher risk of death than patients awaiting elective revascularization (risk ratio at least 2.8). Individual studies identified angina severity and left ventricular dysfunction as most important predictors of death when awaiting CABG. Adverse rates per 1000 patient-weeks for patients awaiting PCI were 0.1 [95% confidence interval 0.0-0.4] for death, 0.4 [0.1-1.2] for non-fatal MI and 0.7 [0.4-1.4] for emergency revascularization but were based on only a few old studies. CONCLUSIONS: Rates of death, non-fatal MI and emergency revascularization when awaiting myocardial revascularization are infrequent but higher in specific patients. Countries that not yet have treatment recommendations related to waiting times should consider introducing a maximum to limit adverse events, particularly when awaiting CABG.
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