Noam Fink1, Eugenia Nikolsky2, Abid Assali3, Oz Shapira4, Yigal Kassif5, Yaron D Barac6, Ariel Finkelstein7, Amnon Eitan2, Haim Danenberg8, Doron Zahger9, Gideon Sahar10, Shaul Atar11, Ehud Raanani5, Gil Bolotin12, Ilan Goldenberg5, Amit Segev5. 1. Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel. Electronic address: noamfink@bezeqint.net. 2. Division of Cardiology, Rambam Healthcare Center, Haifa, Israel. 3. Division of Cardiology, Rabin Medical Center, Petach-Tikva, Israel. 4. Department of Cardiac Surgery, Hadassah Medical Center, Jerusalem, Israel. 5. Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel. 6. Department of Cardiac Surgery, Rabin Medical Center, Petach-Tikva, Israel. 7. Division of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel. 8. Division of Cardiology, Hadassah Medical Center, Jerusalem, Israel. 9. Division of Cardiology, Soroka Medical Center, Beer-Sheva, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. 10. Department of Cardiac Surgery, Soroka Medical Center, Beer-Sheva, Israel. 11. Division of Cardiology, Galilee Medical Center, Naharyiah, Faculty of Medicine in the Galilee, Bar Ilan University, Ramat Gan, Israel. 12. Department of Cardiovascular Surgery, Rambam Healthcare Center, Haifa, Israel.
Abstract
BACKGROUND: We sought to assess real-world implementation of the guidelines in patients with multivessel coronary artery disease (CAD) using a prospective national registry in Israel. METHODS: All consecutive patients with left main or 2- to 3-vessel CAD involving the proximal or mid left anterior descending artery were enrolled in a dedicated multicenter registry. Patients were managed at the discretion of the treating team at each hospital and were followed for 30 months. RESULTS: This registry included 1,064 patients, 55% treated with percutaneous coronary intervention (PCI) and 45% with coronary artery bypass surgery (CABG). Multivariate logistic regression analysis showed that chronic renal failure (odds ratio [OR], 2.43; p = 0.001) and prior myocardial infarction (OR, 1.7; p = 0.024) were associated with referral to PCI versus CABG, whereas male gender (OR, 2.27; p < 0.001), prior aspirin treatment (OR, 1.72; p = 0.005), diabetes mellitus (OR, 1.51; p = 0.007), 3-vessel CAD (OR, 3.45; p < 0.001) and SYNTAX score (SS) greater than 32 (OR, 10.0; p < 0.001) were associated with referral to CABG versus PCI. Each point increment in the SS was independently associated with a 9% greater likelihood of referral to CABG (p < 0.001). Survival analysis showed that mortality risk was lower among PCI patients less than 8 months after the procedure, and CABG was associated with a significant survival benefit thereafter. CONCLUSIONS: We found good agreement with current guidelines regarding revascularization strategies in real-world patients with multivessel CAD. The SS was the main independent predictor associated with the choice of revascularization strategy. The time-dependent association between revascularization strategy and long-term survival should be incorporated in the risk assessment of this population.
BACKGROUND: We sought to assess real-world implementation of the guidelines in patients with multivessel coronary artery disease (CAD) using a prospective national registry in Israel. METHODS: All consecutive patients with left main or 2- to 3-vessel CAD involving the proximal or mid left anterior descending artery were enrolled in a dedicated multicenter registry. Patients were managed at the discretion of the treating team at each hospital and were followed for 30 months. RESULTS: This registry included 1,064 patients, 55% treated with percutaneous coronary intervention (PCI) and 45% with coronary artery bypass surgery (CABG). Multivariate logistic regression analysis showed that chronic renal failure (odds ratio [OR], 2.43; p = 0.001) and prior myocardial infarction (OR, 1.7; p = 0.024) were associated with referral to PCI versus CABG, whereas male gender (OR, 2.27; p < 0.001), prior aspirin treatment (OR, 1.72; p = 0.005), diabetes mellitus (OR, 1.51; p = 0.007), 3-vessel CAD (OR, 3.45; p < 0.001) and SYNTAX score (SS) greater than 32 (OR, 10.0; p < 0.001) were associated with referral to CABG versus PCI. Each point increment in the SS was independently associated with a 9% greater likelihood of referral to CABG (p < 0.001). Survival analysis showed that mortality risk was lower among PCI patients less than 8 months after the procedure, and CABG was associated with a significant survival benefit thereafter. CONCLUSIONS: We found good agreement with current guidelines regarding revascularization strategies in real-world patients with multivessel CAD. The SS was the main independent predictor associated with the choice of revascularization strategy. The time-dependent association between revascularization strategy and long-term survival should be incorporated in the risk assessment of this population.