Optimal medical therapy improves clinical outcomes in patients undergoing revascularization with PCI or CABG
Selected in Circulation by G.G. Stefanini
Insights from the synergy between percutaneous coronary intervention with TAXUS and cardiac surgery (SYNTAX) trial at the 5-year follow-up
Javaid Iqbal, MRCP, PhD*; Yao-Jun Zhang, MD*; David R. Holmes, MD; Marie-Claude Morice, MD; Michael J. Mack, MD; Arie Pieter Kappetein, MD, PhD; Ted Feldman, MD; Elizabeth Stahle, MD; Javier Escaned, MD, PhD; Adrian P. Banning, MD, FRCP; Julian P. Gunn, MD, MRCP; Antonio Colombo, MD; Ewout W. Steyerberg, PhD; Friedrich W. Mohr, MD; Patrick W. Serruys, MD, PhD
Circulation. 2015; 131: 1269-1277
February 24, 2015
LinkAccess the abstract
What is known
Patients with coronary artery disease undergoing myocardial revascularisation should receive optimal medical therapy (OMT) for secondary prevention in order to reduce the risk of disease progression. However, available evidence suggests that use of medications remains suboptimal after revascularisation procedures. This underuse might be explained by medication nonadherence, healthcare systems-related issues, or paucity of data leading to an underestimation of the importance of OMT after revascularisation.
Aim of the study
To evaluate the use of OMT after myocardial revascularisation and its long-term prognostic impact in patients with complex coronary artery disease included in the SYNTAX trial.
- The authors performed an analysis of the SYNTAX trial, in which 1800 patients with three-vessel or left main disease were randomly allocated to CABG or PCI with paclitaxel-eluting stents.
- Medication status was checked for all patients at baseline, discharge, 1 month, 6 months, 1 year, 3 years, and 5 years.
- OMT was defined as the combination of at least 1 antiplatelet agent, statin, beta-blocker, and ACE-inhibitor.
- Pre-specified endpoints were all-cause mortality and a composite of all-cause death, myocardial infarction and stroke at 5 years.
- 5-year outcomes were stratified according to OMT status (ie, OMT vs non-OMT).
- Comparisons between groups were performed with Cox regression with OMT used as a time-dependent co-variate.
- OMT was underused in patients undergoing myocardial revascularisation, especially CABG (OMT at discharge: 50.2% in the PCI group, 32.2% in the CABG group; OMT at 5 years: 39.6% in the PCI group, 35.7% in the CABG group).
- OMT was identified as an independent predictor of survival.
- OMT was associated with a significant reduction in all-cause mortality (HR 0.64, 95% CI 0.48-0.85) and of the composite of all-cause death, myocardial infarction and stroke (HR 0.73, 95% CI 0.58-0.92).
The results of this analysis show that only one-third of patients with complex coronary artery disease undergoing myocardial revascularisation receive OMT at 5 years of follow-up, and that lack of OMT was associated with a higher risk of all-cause mortality and ischemic events. These findings are consistent with previous studies of lower-risk populations. It is worth to underscore that coronary artery disease is a systemic disease and may involve multiple segments within the coronary artery tree. Therefore, OMT plays an important role in reducing the risk of disease progression and the propensity for new plaque rupture with subsequent ischemic events.
Overall, this analysis reinforces the importance of OMT for patients with complex CAD undergoing revascularisation. Considering greater benefits at earlier time-points it is best to ensure that OMT is initiated as soon as possible after myocardial revascularisation. Moreover, the importance of OMT should be emphasized to each patient in order to improve compliance. Additional studies to understand the reasons for OMT underuse and potential interventions to improve OMT use and adherence are needed.