Prognostic importance of coronary anatomy and left ventricular ejection fraction despite optimal therapy: Assessment of residual risk in the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation Trial - 07/09/13

Doi : 10.1016/j.ahj.2013.07.007

G.B. John Mancini, MD ^a,^{^⁎,}^{^{p
On behalf of the COURAGE Investigators.}} , Pamela M. Hartigan, PhD ^b,^{^{p
On behalf of the COURAGE Investigators.}}, Eric R. Bates, MD ^c,^{^{p
On behalf of the COURAGE Investigators.}}, Bernard R. Chaitman, MD ^d,^{^{p
On behalf of the COURAGE Investigators.}}, Steven P. Sedlis, MD ^e,^{^{p
On behalf of the COURAGE Investigators.}}, David J. Maron, MD ^f,^{^{p
On behalf of the COURAGE Investigators.}}, William J. Kostuk, MD ^g,^{^{p
On behalf of the COURAGE Investigators.}}, John A. Spertus, MD ^h,^{^{p
On behalf of the COURAGE Investigators.}}, Koon K. Teo, MD ^i,^{^{p
On behalf of the COURAGE Investigators.}}, Marcin Dada, MD ^j,^{^{p
On behalf of the COURAGE Investigators.}}, Merril Knudtson, MD ^k,^{^{p
On behalf of the COURAGE Investigators.}}, Daniel S. Berman, MD ^l,^{^{p
On behalf of the COURAGE Investigators.}}, David C. Booth, MD ^m,^{^{p
On behalf of the COURAGE Investigators.}}, William E. Boden, MD ^n,^{^{p
On behalf of the COURAGE Investigators.}}, William S. Weintraub, MD ^o,^{^{p
On behalf of the COURAGE Investigators.}}
^a University of British Columbia, Vancouver, British Columbia, Canada
^b Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT
^c University of Michigan Medical Center, Ann Arbor, MI
^d St Louis University Hospital, St Louis, MO
^e VA New York Harbor Health Care System, New York Campus, New York University School of Medicine, New York, NY
^f Vanderbilt University Medical Center, Nashville, TN
^g London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
^h Mid America Heart Institute, University of Missouri, Kansas City, MO
ⁱ McMaster University Medical Center, Hamilton, Ontario, Canada
^j Hartford Hospital, Hartford, CT
^k University of Calgary, Calgary, Alberta, Canada
^l Cedars-Sinai Heart Institute, University of California, Los Angeles, CA
^m University of Kentucky, Lexington, KY
ⁿ New York Health Care System, Buffalo General Hospital and the State University of New York at Buffalo, NewYork, NY
^o Christiana Care Health System, Newark, DE

^⁎Reprint requests: G.B. John Mancini, Vancouver Hospital Research Pavilion, Room 489, 828 West 10th Ave, Vancouver, British Columbia V5Z 1M9.

Résumé

Background

It is unknown if baseline angiographic findings can be used to estimate residual risk of patients with chronic stable angina treated with both optimal medical therapy (OMT) and protocol-assigned or symptom-driven percutaneous coronary intervention (PCI).

Methods

Death, myocardial infarction (MI), and hospitalization for non–ST-segment elevation acute coronary syndrome were adjudicated in 2,275 COURAGE patients. The number of vessels diseased (VD) was defined as the number of major coronary arteries with ≥50% diameter stenosis. Proximal left anterior descending, either isolated or in combination with other disease, was also evaluated. Depressed left ventricular ejection fraction (LVEF) was defined as ≤50%. Cox regression analyses included these anatomical factors as well as interaction terms for initial treatment assignment (OMT or OMT + PCI).

Results

Percutaneous coronary intervention and proximal left anterior descending did not influence any outcome. Death was predicted by low LVEF (hazard ratio [HR] 1.86, CI 1.34-2.59, P < .001) and VD (HR 1.45, CI 1.20-1.75, P < .001). Myocardial infarction and non–ST-segment elevation acute coronary syndrome were predicted only by VD (HR 1.53, CI 1.30-1.81 and HR 1.24, CI 1.06-1.44, P = .007, respectively).

Conclusions

In spite of OMT and irrespective of protocol-assigned or clinically driven PCI, LVEF and angiographic burden of disease at baseline retain prognostic power and reflect residual risk for secondary ischemic events.

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Clinical Trial Registration: www.clinicaltrials.gov no. NCT00007657.

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Vol 166 - N° 3

P. 481-487 - septembre 2013 Retour au numéro

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Prognostic importance of coronary anatomy and left ventricular ejection fraction despite optimal therapy: Assessment of residual risk in the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation Trial - 07/09/13

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Background

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Conclusions

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