Stroke Rates Following Surgical Versus Percutaneous Coronary Revascularization

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

卷:72

Article

Head, Stuart J.¹  Milojevic, Milan¹  Daemen, Joost²  Ahn, Jung-Min³  Boersma, Eric²  Christiansen, Evald H.⁴  Domanski, Michael J.^5,6,7  Farkouh, Michael E.^5,6,7  Flather, Marcus^8,9  Fuster, Valentin⁵  Hlatky, Mark A.^10,11  Holm, Niels R.⁴  Hueb, Whady A.¹²  Kamalesh, Masoor¹³  Kim, Young-Hak³  Makikallio, Timo¹⁴  Mohr, Friedrich W.¹⁵  Papageorgiou, Grigorios^1,16  Park, Seung-Jung³  Rodriguez, Alfredo E.¹⁷  Sabik, Joseph F., III¹⁸  Stables, Rodney H.¹⁹  Stone, Gregg W.^20,21  Serruys, Patrick W.^1,22 

[1] Erasmus MC, Dept Cardiothorac Surg, Rotterdam, Netherlands

[2] Erasmus Med Coll, Dept Cardiol, Rotterdam, Netherlands

[3] Univ Ulsan, Coll Med, Asan Med Ctr, Dept Cardiol, Seoul, South Korea

[4] Aarhus Univ Hosp, Dept Cardiol, Aarhus, Denmark

[5] Icahn Sch Med Mt Sinai, Cardiovasc Inst, New York, NY 10029 USA

[6] Univ Toronto, Heart & Stroke Richard Lewar Ctr, Peter Munk Cardiac Ctr, Div Cardiol, Toronto, ON, Canada

[7] Univ Toronto, Heart & Stroke Richard Lewar Ctr, Dept Med, Toronto, ON, Canada

[8] Univ East Anglia, Norwich Med Sch, Dept Med & Hlth Sci, Norwich, Norfolk, England

[9] Norfolk & Norwich Univ Hosp, Norwich, Norfolk, England

[10] Stanford Univ, Sch Med, Dept Hlth Res & Policy, Stanford, CA USA

[11] Stanford Univ, Sch Med, Dept Med Cardiovasc Med, Stanford, CA USA

[12] Univ Sao Paulo, Med Sch, Heart Inst InCor, Sao Paulo, Brazil

[13] Richard L Roudebush Vet Affairs Med Ctr, Dept Cardiol, 1481 W 10th St, Indianapolis, IN 46202 USA

[14] Oulu Univ Hosp, Dept Cardiol, Oulu, Finland

[15] Herzzentrum Univ Leipzig, Dept Cardiac Surg, Leipzig, Germany

[16] Erasmus MC, Dept Biostat, Rotterdam, Netherlands

[17] Otamendi Hosp, Cardiac Unit, Buenos Aires, DF, Argentina

[18] Univ Hosp Cleveland, Med Ctr, Dept Surg, Cleveland, OH 44106 USA

[19] Liverpool Heart & Chest Hosp, Inst Cardiovasc Med & Sci, Liverpool, Merseyside, England

[20] Columbia Univ, Med Ctr, Dept Cardiol, New York, NY USA

[21] Cardiovasc Res Fdn, Clin Trials Ctr, New York, NY USA

[22] Imperial Coll London, Dept Cardiol, London, England

关键词: coronary artery bypass graft;    left main;    mortality;    multivessel;    percutaneous coronary intervention;    stenting;    stroke;   

DOI  :  10.1016/j.jacc.2018.04.071

来源: Elsevier

【 摘 要 】

BACKGROUND Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with large numbers of patients are required to detect differences in stroke rates between CABG and PCI. OBJECTIVES This study sought to compare rates of stroke after CABG and PCI and the impact of procedural stroke on long-term mortality. METHODS We performed a collaborative individual patient-data pooled analysis of 11 randomized clinical trials comparing CABG with PCI using stents; ERACI II (Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease) (n = 450), ARTS (Arterial Revascularization Therapy Study) (n = 1,205), MASS II (Medicine, Angioplasty, or Surgery Study) (n = 408), SoS (Stent or Surgery) trial (n = 988), SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial (n = 1,800), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) trial (n = 600), FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900), VA CARDS (Coronary Artery Revascularization in Diabetes) (n = 198), BEST (Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease) (n = 880), NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trial (n = 1,184), and EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial (n = 1,905). The 30-day and 5-year stroke rates were compared between CABG and PCI using a random effects Cox proportional hazards model, stratified by trial. The impact of stroke on 5-year mortality was explored. RESULTS The analysis included 11,518 patients randomly assigned to PCI (n = 5,753) or CABG (n = 5,765) with a mean follow-up of 3.8 +/- 1.4 years during which a total of 293 strokes occurred. At 30 days, the rate of stroke was 0.4% after PCI and 1.1% after CABG (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.20 to 0.53; p < 0.001). At 5-year follow-up, stroke remained significantly lower after PCI than after CABG (2.6% vs. 3.2%; HR: 0.77; 95% CI: 0.61 to 0.97; p = 0.027). Rates of stroke between 31 days and 5 years were comparable: 2.2% after PCI versus 2.1% after CABG (HR: 1.05; 95% CI: 0.80 to 1.38; p = 0.72). No significant interactions between treatment and baseline clinical or angiographic variables for the 5-year rate of stroke were present, except for diabetic patients (PCI: 2.6% vs. CABG: 4.9%) and nondiabetic patients (PCI: 2.6% vs. CABG: 2.4%) (p for interaction = 0.004). Patients who experienced a stroke within 30 days of the procedure had significantly higher 5-year mortality versus those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and CABG (41.5% vs. 8.9%, p < 0.001). CONCLUSIONS This individual patient-data pooled analysis demonstrates that 5-year stroke rates are significantly lower after PCI compared with CABG, driven by a reduced risk of stroke in the 30-day post-procedural period but a similar risk of stroke between 31 days and 5 years. The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes. Five-year mortality was markedly higher for patients experiencing a stroke within 30 days after revascularization. (C) 2018 by the American College of Cardiology Foundation.

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