Predictors of cardiac death in patients with coronary chronic total occlusion not revascularized by PCI

doi:10.1016/j.ijcard.2012.12.044

International Journal of Cardiology

Volume 168, Issue 2, 30 September 2013, Pages 1402-1409

https://doi.org/10.1016/j.ijcard.2012.12.044 Get rights and content

Abstract

Background

Limited data are available on clinical outcome of patients with previously failed or not attempted chronic total occlusion (CTO) recanalization by percutaneous coronary intervention (PCI). The aim of the study is to determine prevalence and predictors of cardiac death in patients with CTO not revascularized by PCI.

Methods

Double-center study analyzing data of 1.345 consecutive patients with at least one CTO between 1998 and 2008. Of these, 847 patients were successfully revascularized (Revascularized group) and 498 patients were not revascularized (Not revascularized group) either due to failure of CTO-PCI (n = 337) or because no attempt was made (n = 161).

Results

At 4-year clinical follow-up, Not revascularized patients had a significantly higher rate of cardiac mortality (8.5% vs. 2.5%, p < 0.0001) and sudden cardiac death (2.7% vs. 0.5%, p = 0.001) compared to those Revascularized. The separate adjusted Cox-model analysis made for Not revascularized patients showed the most significant independent predictors of cardiac death were: chronic renal failure [HR (CI), 6.0 (2.66–13.80)], low-LVEF [5.7 (2.84–11.58)], insulin-dependent diabetes mellitus (IDDM) 4.6 [(1.96–10.97)]. In the Revascularized group, the presence of 3-vessel disease was the only significant independent predictor of cardiac death [4.4 (1.40–13.70)].

Conclusions

CTO patients Not revascularized had a significant higher rate of cardiac mortality and sudden cardiac death compared to those Revascularized. Within Not revascularized patients, the presence of low-LVEF, or CRF or IDDM was associated with an incidence of cardiac death at least 4 times higher than those without the same risk factors.

Introduction

Coronary chronic total occlusions (CTO) remain a technical challenge and an unresolved clinical dilemma, even in the presence of numerous successes and rapid progression within the field of interventional cardiology. Approximately, 15–30% of all coronary angiograms performed in patients with significant coronary artery disease demonstrate evidence of a CTO,[1], [2] but percutaneous coronary intervention (PCI) for these lesions accounts for only 10–15% of all PCI activity [1], [3]. As shown by previous studies, [4], [5] the rationale behind CTO revascularization is that of improved survival and quality of life [5], [6], [7], [8], [9], [10], [11], [12], [13]. However, still 20–35% of occlusions are not recanalized by PCI even if performed by experienced operators [5], [11] and more than 40% are not attempted and treated with either medical therapy or coronary artery bypass grafting (CABG) surgery [1], [14], [15]. Currently, there is no evidence regarding which category of patients have more benefit from CTO revascularization and conversely, which subgroups of not revascularized patients are at more risk of future cardiac events. Therefore, the current study aimed to evaluate the long-term survival of patients with a CTO, stratified by Revascularized or Not revascularized in order to identify the patients at major risk of cardiac death.

Section snippets

Population

Between January 1998 and March 2008, all consecutive patients who were referred for coronary angiography at San Raffaele Hospital and at EMO-GVM Centro Cuore Columbus, Milan, Italy, were analyzed. The indications for PCI in the presence of CTO were symptomatic myocardial ischemia or evidence of viable myocardium in the territory of the occluded artery (demonstrated either by echocardiography stress test, nuclear medicine or cardiac magnetic resonance imaging). The decision to perform PCI versus

Results

From January 1998 to March 2008, a total of 9.789 consecutive patients were referred to San Raffaele Hospital or to GVM-EMO Centro Cuore Columbus in Milan for coronary angiography and 1.976 (20%) showed at least one occluded coronary vessel. From the total cohort of patients, 1.345 matched the inclusion and exclusion criteria for CTO and were included in the final analysis (Fig. 1). Of these, 847 patients (63%) were successfully recanalized (Revascularized CTO patients) and 498 patients (37%)

Main findings

In this work, we observed that patients with CTO Not revascularized have a cardiac mortality and sudden cardiac death rate significantly higher than those Revascularized. Within the group of Not revascularized patients, the presence of low-LVEF, or CRF or IDDM was associated with an incidence of cardiac death at least 4 times higher than those without the same risk factors. Among Revascularized patients, those with 3-vessel disease had the worst outcome. Finally, between CTO-PCI failed and

Study limitations

In this study findings are derived from a non-randomized double-center study and not from a prospective clinical multicentre study, but the total patient cohort considered was large and regularly followed for an extensive time span. Furthermore, unlike those with a failed recanalization or not attempted CTO, the group with a successful recanalization incorporating stent implantation was treated with additional anti-platelet medical therapy such as clopidogrel or ticlopidine, which could be a

Conclusions

In conclusion, this study shows that in CTO patients Not revascularized the incidences of cardiac death and sudden death were almost 4 and 5 times greater, respectively, compared to those Revascularized. Moreover, within the group of Not revascularized patients, the presence of low-LVEF, or CRF or IDDM was associated with an incidence of cardiac death at least 4 times higher than those without the same risk factors. Therefore, the results suggest that for CTO patients it would be more

Acknowledgment

The authors would like to thank M. Ferraro and A. Amato (EMO GVM Centro Cuore Columbus) for the given support for database management and clinical data collection.

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Percutaneous Coronary Intervention of Chronic Total Occlusion Associated with Higher Inpatient Mortality and Complications Compared With Non-CTO Lesions
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Percutaneous coronary intervention (PCI) in patients with chronic total occlusion is commonly performed despite unclear long-term benefits. The goal of this study was to evaluate the postprocedural outcome of patients with chronic total occlusion intervention.
The National Inpatient Sample database, years 2016-2020, was studied using International Classification of Diseases, Tenth Revision codes. Patients with chronic total occlusion interventions were compared with patients without chronic total occlusion. We evaluated postprocedural mortality and complications.
PCI in patients with chronic total occlusion was associated with higher total inhospital mortality and all postprocedural complications. A weighted total of 10,059,269 patients underwent PCI, with 259,574 having chronic total occlusion. The chronic total occlusion group had a 3.17% mortality rate vs 2.57% of nonchronic total occlusion PCIs (odds ratio [OR] 1.24; 95% confidence interval [CI], 1.18-1.31; P < .001). Using multivariate analysis adjusting for basline charcteristics and high risk features such as age, sex, race, diabetes mellitus, chronic kidney disease, systolic heart failure, 3-vessel PCI, hypertension, chronic obstructive pulmonary disease, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, prior PCI, history of coronary artery bypass graft, history of anemia, smoking status, atrial fibrillation/flutter, valvular heart disease, and , history of stroke, chronic total occlusion PCI remained significantly associated with higher total mortality (OR 1.07; 95% CI, 1.02-1.13; P = .02). Patients with chronic total occlusion compared with nonchronic total occlusion PCI had also higher rates of myocardial infarction (OR 2.85; 95% CI, 2.54-3.21; P < .001), coronary perforation (OR 6.01; 95% CI, 5.25-6.89; P < .001), tamponade (OR 3.36; 95% CI, 2.91-3.88; P < .001), contrast-induced nephropathy (OR 2.05; 95% CI, 1.45-2.90; P < .001), procedural bleeding (OR 3.57; 95% CI, 3.27-3.89; P < .001), and acute postprocedural respiratory failure (OR 2.07; 95% CI, 1.81-2.36; P < .001). All postprocedural complications were more than 3 times the nonchronic total occlusion patients (OR 3.45; 95% CI, 3.24-3.67; P < .001).
Using a large national inpatient database, PCI performed in patients with chronic total occlusion was associated with significantly much higher mortality and postprocedural complications compared with PCI in nonchronic total occlusion patients.
In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Heart failure patients
2023, Current Problems in Cardiology
In-hospital outcomes of chronic total occlusion Percutaneous Coronary Interventions (CTO PCI) in heart failure patients has not been evaluated on a national base and was the focus of this investigation. We used the Nationwide Inpatient Sample database from 2008 to 2014 to identify adults with single vessel CTO PCI for stable ischemic heart disease (SIHD). Patients were divided into 3 groups: patients without heart failure, heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple logistic regression models were performed to assess in-hospital mortality, acute renal failure, and the use of mechanical support devices. Of 112,061 inpatients with SIHD from 2008 to 2014 undergoing CTO PCI, 21,185 (19%) had HFrEF and 3309 (3%) had HFpEF. Compared to patients without heart failure, HFrEF and HFpEF patients were older (mean age 69.2 vs 66.3, 70.3 vs 66.3 respectively, P < 0.001), had more comorbidities and higher acute in-hospital complications. HFrEF patients had higher adjusted in-hospital mortality [AOR 1.73, 95% CI (1.21-2.48)], acute renal failure [AOR 2.68, 95% CI (2.34-3.06)], and need for mechanical support [AOR 2.76, 95% CI (2.17-3.51)]. Compared to patients without heart failure, HFpEF patients had similar mortality and need for mechanical support, but higher incidence of acute renal failure. Older age was significantly associated with increased in-hospital mortality. chronic total occlusion PCI in patients with heart failure is associated with higher in-hospital morbidity and mortality and warrants further investigation to optimize health care delivery.
Prognosis of Patients With Reduced Left Ventricular Ejection Fraction and Chronic Total Occlusion According to Treatment Applied
2021, Cardiovascular Revascularization Medicine
Chronic total occlusion (CTO) is common among patients with coronary artery disease. Very few studies have focused on outcomes of patients with CTO and reduced left ventricular ejection fraction (LVEF), according to treatment applied. The aim of our study was to determine the potential influence of the selected treatment on the prognosis in patients with CTO associated with reduced LVEF.
Between June 2010 and October 2013, all consecutive patients with at least one CTO and reduced LVEF (<40%) were enrolled. Major adverse cardiac events (MACE), defined as the composite of cardiac mortality or myocardial infarction (MI) and its individual components, were compared between three treatment groups: medical therapy (MT), percutaneous coronary intervention (PCI), and coronary bypass graft (CABG).
In 256 included patients, the follow-up was 1129 ± 556 days. The incidence of MACE was 40% in the MT group, compared with PCI (20.3%) and CABG (16.7%); p < 0.001. All-cause and cardiac mortality were also higher in the MT group (40.7% and 33.3%, respectively) versus the PCI (21.9% and 15.6%) and CABG (11.9% and 9.5%) groups (p < 0.001 for both endpoints); MI rate did not differ among groups. In the adjusted multivariate analysis, CABG had lower MACE risk, compared with MT (HR = 0.39, 0.17–0.91; p = 0.029); successful PCI also trended toward lower risk of MACE, compared with MT.
Patients with CTO and reduced LVEF treated with MT had a worse prognosis than those treated with revascularization (either CABG or PCI). Patients with an indication for CABG appeared to perform best during long-term follow-up.
Clinical and Angiographic Features of Patients With Out-of-Hospital Cardiac Arrest and Acute Myocardial Infarction
2020, Journal of the American College of Cardiology
Citation Excerpt :
An observational study (41) of the survivors of ventricular arrhythmias who received implantable cardioverter-defibrillator implantation revealed higher incidence of appropriate implantable cardioverter-defibrillator therapies in the patients with CTO than in those without CTO during a median follow-up of 4 years. Other large observational studies with long-term follow-up (42,43) of the patients who had CTO lesions revealed that patients whose CTO was revascularized by coronary intervention had a significantly lower rate of cardiac mortality and of sudden cardiac death than those whose CTO was not revascularized. Because there is an adequate amount of evidence that the presence of CTO is associated with worse outcome and that revascularization of CTO is associated with the improved outcome, randomized controlled trials are required to confirm the concept that revascularization of CTO improves outcome.
Sudden cardiac arrest is a serious complication of acute myocardial infarction (MI). Although in-hospital mortality from MI has decreased, the mortality of MI patients complicated with out-of-hospital cardiac arrest (OHCA) remains high. However, the features of acute MI patients with OHCA have not been well known.
We sought to characterize the clinical and angiographic features of acute MI patients with OHCA comparing with those without OHCA.
We retrospectively analyzed 480 consecutive patients with acute MI undergoing percutaneous coronary intervention. Patients complicated with OHCA were compared with patients without OHCA.
Of the patients, 141 (29%) were complicated with OHCA. Multivariate analysis revealed that age (odds ratio [OR]: 0.8; 95% confidence interval [CI]: 0.7 to 0.9 per 5 years; p < 0.001), estimated glomerular filtration rate (OR: 0.8; 95% CI: 0.7 to 0.8 per 10 ml/min/1.73 m²; p < 0.001), peak creatine kinase-myocardial band (OR: 1.3; 95% CI: 1.2 to 1.4 per 10² U/l; p < 0.001), calcium-channel antagonists use (OR: 0.4; 95% CI: 0.2 to 0.7; p = 0.002), the culprit lesion at the left main coronary artery (OR: 5.3; 95% CI: 1.9 to 15.1; p = 0.002), and the presence of chronic total occlusion (OR: 2.9; 95% CI: 1.5 to 5.7; p = 0.001) were significantly associated with OHCA.
Younger age, no use of calcium-channel antagonists, worse renal function, larger infarct size, culprit lesion in the left main coronary artery, and having chronic total occlusion were associated with OHCA.
Two-year clinical outcomes of medical therapy vs. revascularization for patients with coronary chronic total occlusion
2020, Hellenic Journal of Cardiology
There are little data on the long-term clinical outcomes of medical therapy (MT) compared with revascularization in patients with chronic total occlusions (CTOs).
Between January 2007 and December 2016, a total of 1655 patients with ≥1 CTO were enrolled in our center and were divided into the MT group (n = 800) and revascularization group (n = 855) according to the initial treatment strategy. Propensity score matching was also performed to adjust for baseline characteristics. The primary outcome was cardiac death.
After 2 years of follow-up, there was no significant difference between the two groups with regard to the prevalence of cardiac death (MT vs. revascularization: 6.6% vs. 4.2%, adjusted hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.60–1.49, p = 0.820). In the propensity-matched population (406 pairs), there were no significant differences in the prevalence of cardiac death (MT vs. revascularization: 5.4% vs. 4.7%, HR 0.88, 95% CI 0.48–1.63, p = 0.694), except for target vessel revascularization (TVR) (0.44, 0.31–0.63, <0.001) and major adverse cardiovascular events (MACE) (0.51, 0.38–0.68, <0.001), between the two groups. There were also no significant differences in the prevalence of cardiac death (MT vs. successful CTO-PCI: 6.6% vs. 4.0%, HR 0.94, 95% CI 0.41–2.15, p = 0.881) between the MT and successful CTO-PCI groups.
As an initial management strategy in patients with CTOs, revascularization did not reduce the risk of cardiac death compared with treatment with medical therapy alone. However, revascularization was associated with reduction in the prevalence of TVR and MACE. Furthermore, successful CTO-PCI was also not associated with improved long-term survival compared with MT alone.
Indications for Percutaneous Coronary Intervention (PCI) in Chronic Total Occlusion (CTO): Have We Reached a DECISION or Do We Continue to EXPLORE After EURO-CTO?
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A coronary chronic total occlusion (CTO) is a common finding during coronary angiography and is associated with increased mortality and poorer cardiovascular prognosis. Technological developments in percutaneous strategies for revascularisation have resulted in increased interest in this area. However, until recently, there has been a paucity of robust scientific randomised data comparing the efficacy of medical management with percutaneous strategies. Both observational data, and to a lesser extent, randomised data, suggest that CTO percutaneous coronary intervention (PCI) should be considered in symptomatic patients. However, in the absence of any randomised data, CTO PCI should not be performed for prognostic benefit. Ongoing trials are needed to confirm these findings as well as to identify the optimal timing and strategy of such interventions.

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Predictors of cardiac death in patients with coronary chronic total occlusion not revascularized by PCI

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Population

Results

Main findings

Study limitations

Conclusions

Acknowledgment

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol.

Int J Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

J Clin Epidemiol

J Clin Epidemiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

JACC Cardiovasc Interv