Revascularization versus Optimal Medical Therapy for Patients With Prior Coronary Artery Bypass Surgery: An Analysis From the Duke Databank for Cardiovascular Disease, Circulation. 2015. Ralf E Harskamp; Karen Chiswell; Sharif Halim; Jennifer Rymer; Linda Shaw; L Kristin Newby.
Cardiology, Duke Clinical Research Institute, Durham, NC
Objectives: To describe treatment strategies of patients with prior coronary artery bypass grafting (CABG) who underwent subsequent coronary angiography and to compare clinical outcomes among patients who underwent coronary revascularization (CR) versus optimal medical therapy (OMT).
Methods: From patients with prior CABG who underwent subsequent non-emergent coronary angiography at Duke University Hospital between January 2003 and October 2012, we identified those with documented stenosis of at least one vessel (native or bypass graft). All patients were followed for subsequent death, MI, or stroke through December 2013. Logistic and Cox-proportional hazards regression models were used for 30-day and 5-year outcomes, respectively.
Results: A total of 3838 patients were included, of whom 1,672 (43.6%) were treated with CR within 30 days of index catheterization (1615 with PCI and 57 with CABG) and 2,166 (56.4%) received OMT. Median age was 66 (IQR 58-74) years; 26.5% were women. Heart failure was more common in the OMT group (NYHA>II, 11.6% vs. 19.7%); ACS was more common in the CR group (44.7% vs. 36.6%). Rates of death, MI, or stroke were 2.4% in both groups at 30 days and 41.2% and 40.6% for CR and OMT, respectively, at 5-years (Figure 1). Adjusted death, MI or stroke rates were similar between groups at 30 days (OR: 1.05, 95% confidence interval (CI): 0.66-1.65, p=0.85) and 5 years (OR: 1.08, 95%-CI: 0.97-1.20, p=0.18). Five-year death or MI (OR: 1.04, 95% CI: 0.93-1.17, p=0.46) and all-cause mortality (OR: 0.93, 95% CI: 0.82-1.06, p=0.26) were also similar.
Conclusion: Among patients with prior CABG who undergo subsequent coronary angiography, long-term outcomes are poor. In a non-randomized comparison, clinical outcomes with CR are similar to those for OMT.