Impact of Optimal Medical Therapy on 10-Year Mortality After Coronary Revascularization

Published on Jul 6, 2021in Journal of the American College of Cardiology20.589
· DOI :10.1016/J.JACC.2021.04.087
Hideyuki Kawashima6
Estimated H-index: 6
(National University of Ireland, Galway),
Patrick W. Serruys212
Estimated H-index: 212
(NIH: National Institutes of Health)
+ 16 AuthorsArie Pieter Kappetein53
Estimated H-index: 53
(EUR: Erasmus University Rotterdam)
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Abstract
Abstract null null Background null The benefit of optimal medical therapy (OMT) on 5-year outcomes in patients with 3-vessel disease and/or left main disease after percutaneous coronary intervention or coronary artery bypass grafting (CABG) was demonstrated in the randomized SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial. null null null Objectives null The objective of this analysis is to assess the impact of the status of OMT at 5 years on 10-year mortality after percutaneous coronary intervention or CABG. null null null Methods null This is a subanalysis of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study, which evaluated for up to 10 years the vital status of patients who were originally enrolled in the SYNTAX trial. OMT was defined as the combination of 4 types of medications: at least 1 antiplatelet drug, statin, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and beta-blocker. After stratifying participants by the number of individual OMT agents at 5 years and randomized treatment, a landmark analysis was conducted to assess the association between treatment response and 10-year mortality. null null null Results null In 1,472 patients, patients on OMT at 5 years had a significantly lower mortality at 10 years compared with those on ≤2 types of medications (13.1% vs 19.9%; adjusted HR: 0.470; 95% CI: 0.292-0.757; P = 0.002) but had a mortality similar to those on 3 types of medications. Furthermore, patients undergoing CABG with the individual OMT agents, antiplatelet drug and statin, at 5 years had lower 10-year mortality than those without. null null null Conclusions null In patients with 3-vessel and/or left main disease undergoing percutaneous coronary intervention or CABG, medication status at 5 years had a significant impact on 10-year mortality. Patients on OMT with guideline-recommended pharmacologic therapy at 5 years had a survival benefit. (Synergy Between PCI With Taxus and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; null NCT00114972 )
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Summary Background Randomised controlled trials are considered the gold standard for testing the efficacy of novel therapeutic interventions, and typically report the average treatment effect as a summary result. As the result of treatment can vary between patients, basing treatment decisions for individual patients on the overall average treatment effect could be suboptimal. We aimed to develop an individualised decision making tool to select an optimal revascularisation strategy in patients wi...
16 CitationsSource
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Resources for clinical research are limited. With increasing demand for patient-centred care, which is growing into an integral component of modern medicine, studying outcomes of patients with specific clinical characteristics is becoming increasingly important. Given the high cost of clinical trials and the time it takes to complete an investigation, it has become compulsory for investigators to assess not only treatment effects between the main randomized groups but also to try to identify cli...
6 CitationsSource
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15 CitationsSource
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#2Susanne Nielsen (University of Gothenburg)H-Index: 8
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AIMS: To evaluate the long-term use of secondary prevention medications [statins, β-blockers, renin-angiotensin-aldosterone system (RAAS) inhibitors, and platelet inhibitors] after coronary artery bypass grafting (CABG) and the association between medication use and mortality. METHODS AND RESULTS: All patients who underwent isolated CABG in Sweden from 2006 to 2015 and survived at least 6 months after discharge were included (n = 28 812). Individual patient data from SWEDEHEART and other mandato...
24 CitationsSource
#1Daniel J F M Thuijs (EUR: Erasmus University Rotterdam)H-Index: 6
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Summary Background The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial was a non-inferiority trial that compared percutaneous coronary intervention (PCI) using first-generation paclitaxel-eluting stents with coronary artery bypass grafting (CABG) in patients with de-novo three-vessel and left main coronary artery disease, and reported results up to 5 years. We now report 10-year all-cause death results. Methods The SYNTAX Extended Survival (SYNTAXES) study is an investigator-dr...
146 CitationsSource
135 CitationsSource
#1Raymond J. Gibbons (Mayo Clinic)H-Index: 113
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Importance This review examines the current state-of-the-art optimal medical therapy (OMT) for patients with known coronary artery disease. This therapy, which is sometimes labeled as secondary prevention , is effective in preventing recurrent events and is recommended by the American College of Cardiology Foundation/American Heart Association guidelines. Optimal medical therapy is of recognized public health benefit. Observations The available evidence from broad patient populations, contempora...
9 CitationsSource
#1Paul Kurlansky (Medical City Dallas Hospital)H-Index: 1
#2Morley A. HerbertH-Index: 45
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view all 4 authors...
Background:Multiple studies have compared coronary artery bypass graft (CABG) with percutaneous coronary interventions (PCI) for coronary revascularization. There is considerable evidence that adhe...
31 CitationsSource
#1Charles D. Resor (Brigham and Women's Hospital)H-Index: 2
#2Ashwin S. Nathan (UPenn: University of Pennsylvania)H-Index: 11
Last. Laura Mauri (Brigham and Women's Hospital)H-Index: 95
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Background:Continued dual antiplatelet therapy and optimal medical therapy (OMT) improve outcomes in selected patient populations with established coronary heart disease, but whether OMT modifies t...
13 CitationsSource
#1Stuart J. Pocock (Lond: University of London)H-Index: 151
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This paper tackles several statistical controversies that are commonly faced when reporting a major clinical trial. Topics covered include: multiplicity of data, interpreting secondary endpoints and composite endpoints, the value of covariate adjustment, the traumas of subgroup analysis, assessing individual benefits and risks, alternatives to analysis by intention to treat, interpreting surprise findings (good and bad), and the overall quality of clinical trial reports. All is put in the contex...
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Cited By1
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#1William E. Boden (BU: Boston University)H-Index: 44
#2Bernard J. Gersh (Mayo Clinic)H-Index: 163
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