Ischemia change in stable coronary artery disease is an independent predictor of death and myocardial infarction.

The aim of this study was to evaluate the independent prognostic significance of ischemia change in stable coronary artery disease (CAD). Recent randomized trials in stable CAD have suggested that revascularization does not improve outcomes compared with optimal medical therapy (MT). In contrast, the nuclear substudy of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial found that revascularization led to greater ischemia reduction and suggested that this may be associated with improved unadjusted outcomes. Thus, the effects of MT versus revascularization on ischemia change and its independent prognostic significance requires further investigation. From the Duke Cardiovascular Disease and Nuclear Cardiology Databanks, 1,425 consecutive patients with angiographically documented CAD who underwent 2 serial myocardial perfusion single-photon emission computed tomography scans were identified. Ischemia change was calculated for patients undergoing MT alone, percutaneous coronary intervention, or coronary artery bypass grafting. Patients were followed for a median of 5.8 years after the second myocardial perfusion scan. Cox proportional hazards regression modeling was used to identify factors independently associated with the primary outcome of death or myocardial infarction (MI). Formal risk reclassification analyses were conducted to assess whether the addition of ischemia change to traditional predictors resulted in improved risk classification for death or MI. More MT patients (15.6%) developed ≥5% ischemia worsening compared with those undergoing percutaneous coronary intervention (6.2%) or coronary artery bypass grafting (6.7%) (p < 0.001). After adjustment for established predictors, ≥5% ischemia worsening remained a significant independent predictor of death or MI (hazard ratio: 1.634; p = 0.0019) irrespective of treatment arm. Inclusion of ≥5% ischemia worsening in this model resulted in significant improvement in risk classification (net reclassification improvement: 4.6%, p = 0.0056) and model discrimination (integrated discrimination improvement: 0.0062, p = 0.0057). In stable CAD, ischemia worsening is an independent predictor of death or MI, resulting in significantly improved risk reclassification when added to previously known predictors.

Farzaneh-Far A ，Phillips HR ，Shaw LK ，Starr AZ ，Fiuzat M ，O'Connor CM ，Sastry A ，Shaw LJ ，Borges-Neto S ... -  《-》

Preoperative coronary artery revascularization and long-term outcomes following abdominal aortic vascular surgery in patients with abnormal myocardial perfusion scans: a subgroup analysis of the coronary artery revascularization prophylaxis trial.

Abdominal aortic operations have the highest perioperative cardiac risk. To test the impact of preoperative coronary artery revascularization (PR) in this high-risk subset, a post hoc analysis was performed in patients undergoing aortic surgery within the Coronary Artery Revascularization Prophylaxis (CARP) trial. The study cohort was a subset of 109 CARP patients with myocardial ischemia on nuclear imaging randomized to a strategy of PR (N = 52) or no PR (N = 57) before their scheduled abdominal aortic vascular operation. The clinical indications for vascular surgery were an expanding aneurysm (N = 62) or severe claudication (N = 47). The composite end-point of death and nonfatal myocardial infarction (MI) was determined by an intention-to-treat analysis following randomization. The median time (Interquartiles) from randomization to vascular surgery was 56 (40, 81) days in patients assigned to PR and 19 (10, 43) days in patients assigned to no PR (P < 0.001). At 2.7 years following randomization, the probability of remaining free of death and nonfatal MI was 0.65 with PR and 0.55 with no PR [unadjusted P = 0.08, odds ratio = 1.67, 95% confidence interval (0.93, 2.99)]. Using a Cox proportional hazard model, predictors of the composite of death and nonfatal MI (odds ratio; 95% confidence interval) were no PR (1.90; 1.06-3.43; P = 0.03) and anterior ischemia on preoperative imaging (1.79; 0.99-3.23; P = 0.07). In patients with an abnormal cardiac imaging before abdominal aortic vascular surgery, PR was associated with a reduced risk of death and nonfatal MI while anterior ischemia was an identifier of poor outcome independent of the revascularization status.

Garcia S ，Rider JE ，Moritz TE ，Pierpont G ，Goldman S ，Larsen GC ，Shunk K ，Littooy F ，Santilli S ，Rapp J ，Reda DJ ，Ward HB ，McFalls EO ... -  《-》

Ten-year outcomes of patients randomized to surgery, angioplasty, or medical treatment for stable multivessel coronary disease: effect of age in the Medicine, Angioplasty, or Surgery Study II trial.

With progressive aging, coronary artery disease has been diagnosed at more advanced ages. Although patients aged 65 years or more have been referred to surgical or percutaneous coronary interventions, the best option for coronary artery disease treatment remains uncertain. The current study compared the 3 treatment options for coronary artery disease in patients aged 65 years or more and analyzed the impact of age in treatment options. Patients were separated according to age: 65 years or more (n = 200) and less than 65 years (n = 411). All patients were followed for 10 years. The rates of overall mortality, acute myocardial infarction, and new revascularizations were analyzed. Of 200 patients aged 65 years or more, 68 were randomized to medical therapy, 68 were randomized to percutaneous coronary intervention, and 64 were randomized to coronary artery bypass grafting. At 10 years, overall survival was 63% (medical therapy), 69% (percutaneous coronary intervention), and 66% (coronary artery bypass grafting) (P = .93). The survival free of combined events was 43% (medical therapy), 38% (percutaneous coronary intervention ), and 66% (coronary artery bypass grafting) (P = .007). The survival free of myocardial infarction was 82% (medical therapy), 77% (percutaneous coronary intervention), and 90% (coronary artery bypass grafting) (P = .17), and survival free of new revascularizations was 59% (medical therapy), 58% (percutaneous coronary intervention ), and 91% (coronary artery bypass grafting) (P = .0003). When the 2 age groups were compared, survival free of myocardial infarction for patients treated by percutaneous coronary intervention was 77% (older patients) and 92% (younger patients) (P = .004). In this analysis, treatment options for patients aged 65 years or more who have coronary artery disease yield similar overall survival. However, coronary artery bypass grafting was associated with fewer coronary events, and percutaneous coronary intervention was associated with a higher incidence of myocardial infarction.

Rezende PC ，Hueb W ，Garzillo CL ，Lima EG ，Hueb AC ，Ramires JA ，Kalil Filho R ... -  《-》

Improved near-term coronary artery disease risk classification with gated stress myocardial perfusion SPECT.

We compared analytical approaches to estimate the added value of myocardial perfusion single-photon emission computed tomography (MPS) variables in estimating coronary artery disease (CAD) outcomes. Stress MPS markers of regional ischemia are strong estimators of prognosis. Evidence published to date has not compared analytical methods to establish the added value of stress MPS and to define a clinically meaningful approach to detect improve classification of risk. A total of 4,575 patients were consecutively and prospectively enrolled in the Myoview Prognosis Registry. Multivariable Cox proportional hazards model were employed to estimate CAD death or myocardial infarction (MI). Risk reclassification methods were also calculated. In risk-adjusted models (including age, sex, presenting symptoms, stress type, CAD history, and risk factors), stress MPS ischemia, rest and post-stress left ventricular ejection fraction (LVEF) (all p < 0.0001) were all significant estimators of CAD death or MI. In this multivariable model, 34% of the model chi-square was contributed by MPS ischemia. In receiver-operating characteristic curve analysis, the area under the curve increased from 0.61 to 0.66 when rest and post-stress LVEF were combined with pre-test CAD likelihood (p < 0.0001), increasing to 0.69 for MPS ischemia (p < 0.0001). The net reclassification improvement (NRI) by adding the Duke Treadmill Score (DTS) to a model including pre-test CAD likelihood was 0.112. The cost per NRI was $57 for the exercise test as compared with an office visit for risk stratification purposes. Further, the NRI by adding MPS ischemia to a model with the DTS and pre-test CAD likelihood was 0.358. The cost per NRI was $615 for the stress MPS as compared with an exercise test. Stress-induced ischemia is independently predictive of near-term CAD outcomes. Analytical approaches that establish the reclassification of events provide a unique approach and may serve as a quality imaging metric for estimation of improved health outcomes for stress MPS as well as for comparison to other imaging modalities.

Shaw LJ ，Wilson PW ，Hachamovitch R ，Hendel RC ，Borges-Neto S ，Berman DS ... -  《-》

Long-term follow-up of a randomized, controlled clinical trial of three therapeutic strategies for multivessel stable coronary artery disease in women.

Coronary artery disease is the leading cause of death in women. The proposed treatments for women are similar to those for men. However, in women with multivessel stable coronary artery disease and normal left ventricular function, the best treatment is unknown. A post hoc analysis of the MASS II study with 10 years of follow-up, mean (standard deviation) 6.8 (3.7) years, enrolled between May 1995 and May 2000, evaluated 188 women with chronic stable multivessel coronary artery disease who underwent medical treatment, percutaneous coronary intervention or coronary artery bypass graft surgery. Primary end-points were incidence of total mortality, Q-wave myocardial infarction, or refractory angina. Data were analysed according to the intention-to-treat principle. Women treated with percutaneous coronary intervention and medical treatment had more primary events than those treated with coronary artery bypass graft surgery, respectively, of 34, 44 and 22% (P = 0.003). Survival rates at 10 years were 72% for coronary artery bypass graft surgery, 72% for percutaneous coronary intervention and 56% for medical treatment (P = 0.156). For the composite end-point, Cox regression analysis adjusted for age, diabetes, hypertension, treatment allocation, prior myocardial infarction, smoking, number of vessels affected and total cholesterol, had a higher incidence of primary events with medical treatment than with coronary artery bypass graft surgery [hazard ratio (HR) = 2.38 (95% confidence interval (CI): 1.40-4.05); P = 0.001], a lower incidence with percutaneous coronary intervention than with medical treatment [HR = 0.60 (95% CI: 0.38-0.95); P = 0.031] but no differences between coronary artery bypass graft surgery and percutaneous coronary intervention. Regarding death, a protective effect was observed with percutaneous coronary intervention compared with medical treatment [HR = 0.44 (95% CI: 0.21-0.90); P = 0.025]. Percutaneous coronary intervention and coronary artery bypass graft surgery compared with medical treatment had better results after 10 years of follow-up.

Mansur Ade P ，Hueb WA ，Takada JY ，Avakian SD ，Soares PR ，Garzilo CL ，Kalil Filho R ，Ramires JA ... -  《-》