Riccardo Liga1,2, Danilo Neglia3,4, Samuele Cavaleri3, Enrico Grasso3, Assuero Giorgetti3, Alessia Gimelli5. 1. Dipartimento Cardio-Toracico e Vascolare, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy. 2. Dipartimento di Patologia Chirurgica, Medica, Molecolare e dell'Area Critica, Università di Pisa, Pisa, Italy. 3. Cardiovascular and Imaging Departments, CNR Research Area, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124, Pisa, Italy. 4. Scuola Superiore Sant'Anna, Pisa, Italy. 5. Cardiovascular and Imaging Departments, CNR Research Area, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124, Pisa, Italy. gimelli@ftgm.it.
Abstract
BACKGROUND: In stable coronary artery disease (CAD), the prognostic interaction between clinical variables and treatment appropriateness based on anatomic/functional phenotype needs to be evaluated. METHODS: 1585 consecutive patients underwent myocardial perfusion scintigraphy and coronary angiography within 90 days. Obstructive CAD (> 70% stenosis) with downstream moderate-to-severe ischemia (> 10%) was considered significant. Coronary revascularization was considered appropriate if all hemodynamically significant lesions were revascularized, while medical therapy only was deemed appropriate in the absence of hemodynamically significant CAD. RESULTS: Obstructive CAD and moderate-to-severe ischemia were documented in 1184 (75%) and 466 (29%) patients, respectively. Over mean follow-up of 4.7 ± 2.5 years, the primary endpoint (cardiac death and non-fatal myocardial infarction) occurred in 132 (8.2%) patients. Of patients with obstructive CAD, 797 (67%) were managed appropriately. Patients' management was inappropriate in 389 patients, because either non-hemodynamically significant lesions were revascularized (50%, including 2 patients with non-obstructive lesions being inappropriately revascularized) or ischemia-causing CAD was left untreated (50%). At multivariate analysis, an inappropriate management (P < .001) was correlated with the primary endpoint, together with previous myocardial infarction (P = .009), lower ejection fraction (P < .001) and higher glucose levels (P < .001). CONCLUSIONS: In stable CAD patients, management based on anatomic/functional phenotyping was correlated with a prognostic advantage at long-term follow-up. Correlation between treatment categories and patients' prognosis. A significantly higher event-rate was observed in patients where hemodynamically significant coronary lesions were left untreated-either because MT was not-adherently chosen or in the case of incomplete revascularization-than in those that were revascularized completely (17.6% vs 5.1%; P < .001). Conversely, the revascularization of non-hemodynamically significant CAD correlated with a higher event-rate than that of similar patients managed medically (13.8% vs 8.3%, P = .04). The event-rate of patients in whom coronary revascularization was performed in the presence of hemodynamically significant CAD ('appropriate revascularization') was similar to those with "No CAD/non-obstructive CAD" (5.1% vs 3.5%; P = NS).
BACKGROUND: In stable coronary artery disease (CAD), the prognostic interaction between clinical variables and treatment appropriateness based on anatomic/functional phenotype needs to be evaluated. METHODS: 1585 consecutive patients underwent myocardial perfusion scintigraphy and coronary angiography within 90 days. Obstructive CAD (> 70% stenosis) with downstream moderate-to-severe ischemia (> 10%) was considered significant. Coronary revascularization was considered appropriate if all hemodynamically significant lesions were revascularized, while medical therapy only was deemed appropriate in the absence of hemodynamically significant CAD. RESULTS: Obstructive CAD and moderate-to-severe ischemia were documented in 1184 (75%) and 466 (29%) patients, respectively. Over mean follow-up of 4.7 ± 2.5 years, the primary endpoint (cardiac death and non-fatal myocardial infarction) occurred in 132 (8.2%) patients. Of patients with obstructive CAD, 797 (67%) were managed appropriately. Patients' management was inappropriate in 389 patients, because either non-hemodynamically significant lesions were revascularized (50%, including 2 patients with non-obstructive lesions being inappropriately revascularized) or ischemia-causing CAD was left untreated (50%). At multivariate analysis, an inappropriate management (P < .001) was correlated with the primary endpoint, together with previous myocardial infarction (P = .009), lower ejection fraction (P < .001) and higher glucose levels (P < .001). CONCLUSIONS: In stable CAD patients, management based on anatomic/functional phenotyping was correlated with a prognostic advantage at long-term follow-up. Correlation between treatment categories and patients' prognosis. A significantly higher event-rate was observed in patients where hemodynamically significant coronary lesions were left untreated-either because MT was not-adherently chosen or in the case of incomplete revascularization-than in those that were revascularized completely (17.6% vs 5.1%; P < .001). Conversely, the revascularization of non-hemodynamically significant CAD correlated with a higher event-rate than that of similar patients managed medically (13.8% vs 8.3%, P = .04). The event-rate of patients in whom coronary revascularization was performed in the presence of hemodynamically significant CAD ('appropriate revascularization') was similar to those with "No CAD/non-obstructive CAD" (5.1% vs 3.5%; P = NS).
Authors: Danilo Neglia; Daniele Rovai; Chiara Caselli; Mikko Pietila; Anna Teresinska; Santiago Aguadé-Bruix; Maria Nazarena Pizzi; Giancarlo Todiere; Alessia Gimelli; Stephen Schroeder; Tanja Drosch; Rosa Poddighe; Giancarlo Casolo; Constantinos Anagnostopoulos; Francesca Pugliese; Francois Rouzet; Dominique Le Guludec; Francesco Cappelli; Serafina Valente; Gian Franco Gensini; Camilla Zawaideh; Selene Capitanio; Gianmario Sambuceti; Fabio Marsico; Pasquale Perrone Filardi; Covadonga Fernández-Golfín; Luis M Rincón; Frank P Graner; Michiel A de Graaf; Michael Fiechter; Julia Stehli; Oliver Gaemperli; Eliana Reyes; Sandy Nkomo; Maija Mäki; Valentina Lorenzoni; Giuseppe Turchetti; Clara Carpeggiani; Martina Marinelli; Stefano Puzzuoli; Maurizio Mangione; Paolo Marcheschi; Fabio Mariani; Daniela Giannessi; Stephan Nekolla; Massimo Lombardi; Rosa Sicari; Arthur J H A Scholte; José L Zamorano; Philipp A Kaufmann; S Richard Underwood; Juhani Knuuti Journal: Circ Cardiovasc Imaging Date: 2015-03 Impact factor: 7.792