Main predictors of in-hospital adverse outcomes in non-ST elevation acute coronary syndrome patients with multivessel disease

Aim. To evaluate the range of risk factors associated with adverse cardiovascular events onset in hospital period of follow-up in patients with non-ST elevation acute coronary syndrome (NSTEACS) with multivessel disease (MD).

Material and methods. To the study, under the framework of prospective, single-center registry, the NSTEACS and MD patients were included. Depending on the strategy of revascularization, three groups were selected: staged PCI, coronary bypass (CBG) and PCI as the first with CBG as the second stage. As adverse cardiovascular events, the following were taken: death, myocardial infarction, stroke or transient cerebral ishemia, clinically significant bleeding by BARC, repeat nonscheduled revascularization of target vessel. 

Results. Analysis revealed the groups of factors increasing the probability of adverse cardiovascular events. Those are: (1) clinical and demographic  — older age, diabetes, postinfarction cardiosclerosis, multifocal atherosclerosis, chronic renal failure; (2) coronary and surgical — left main stem lesion, severe atherosclerosis by SYNTAX Score, high surgical risk by EuroScore II, revascularization strategy;  (3) predominance of low or moderate risk by GRACE comparing with high risk.

Conclusion. The results have confirmed high predictional significance of clinical and demography and coronary factors for development of adverse cardiovascular diseases. A significant finding of the study was the fact that in a hospital with surgery and endovascular treatment available 24/7, the intermediate and low GRACE risk in NSTEACS and MD is a factor of adverse cardiovascular events development due to revascularization delays if the risk is not high.

1. Yeh RW, SidneyS. Population trends in the incidence and outcomes of acute myocardial infarction. New England Journal of Medcine. 2010;362(23):2155-65. doi:10.1056/NEJMoa0908610.

2. Chang M, Lee CW, Ahn JM. Predictors of long-term outcomes after bypass grafting versus drug-eluting stent implantation for left main or multivessel coronary artery disease.Catheter Cardiovasc Interv. 2017;1;90(2):177-85. doi:10.1002/ccd.26927.

3. Gnavi R, Rusciani R. Gender, socioeconomic position, revascularization procedures and mortality in patients presenting with STEMI and NSTEMI in the era of primary PCI. Differencesorinequities? Int J Cardiol. 2014;176(3):724-30. doi:10.1016.

4. Fukui T, Tabata M. Early and long-term outcomes of coronary artery bypass grafting and percutaneous coronary intervention in patients with left main disease: singlecenter results of multidisciplinary decision making. Gen Thorac Cardiovasc Surg. 2014;62(5):301-7. doi:10.1007/s11748.

5. Bangalore S, Toklu B, Feit F. Outcomes with coronary artery bypass graft surgery versus percutaneous coronary intervention for patientswith diabetes mellitus: can newer generation drug-eluting stents bridge the gap? Circ Cardiovasc Interv. 2014;7(4):518-25. doi:10.1161/CIRCINTERVENTIONS.114.001970.

6. Sargin M, Tatlisu MA, Mete MT. Stent versus bypass: The reasons and risk factors for early readmission to hospital after myocardial revascularization. North ClinIstanb. 2016;3(1):27-33. doi:10.14744/nci.2016.43434.

7. Zheng Z, Xu B, Zhang H, Guan C. Coronary Artery Bypass Graft Surgery and Percutaneous Coronary Interventions in Patients With Unprotected Left Main Coronary Artery Disease. JACC CardiovascInterv. 2016;9(11):1102-11. doi:10.1016/j.jcin.2016.03.039.

8. Bundhun PK, Wu ZJ, Chen MH. Coronary artery bypass surgery compared with percutaneous coronary interventions in patients with insulin-treated type 2 diabetes mellitus: a systematic review and meta-analysis of 6 randomized controlled trials. Cardiovasc Diabetol. 2016;15(2):1105 -09. doi:10.1186/s12933-015-0323-z.

9. Collet CJ-Ph, Mueller Ch, Roffi M, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2015;831-72. doi:10.1093/eurheartj/ehv320.

10. Cavalcante R, Sotomi Y, Lee CW. OutcomesAfter Percutaneous Coronary Intervention or Bypass Surgery in Patients With Unprotected Left Main Disease. JACC. 2016;68(10):999-1009. doi:10.1016/j.jacc.2016.06.024.

11. Pereg D, Fefer P, Samuel M. Long-term Follow-up of Coronary Artery Bypass Patients With Preoperative and New Postoperative Native Coronary Artery Chronic Total Occlusion. Can J Cardiol. 2016;32(11):1326-31. doi:10.1016/j.cjca.2016.01.015.

12. Ueki C, Miyata H, Motomura N. Previous Percutaneous Coronary Intervention Does Not Increase Adverse Events After Coronary Artery Bypass Surgery. Ann Thorac Surg. 2017;pii:S0003-4975(16)31477-1. doi:10.1016/j.athoracsur.2016.10.028. [Epub ahead of print].

13. Bundhun PK, Pursun M, Teeluck AR. Adverse Cardiovascular Outcomes associated with Coronary Artery Bypass Surgery and Percutaneous Coronary Intervention with Everolimus Eluting Stents: A Meta-Analysis. SciRep. 2016;6:35869. doi:10.1038/srep35869.

14. Luthra S, LeivaJuárez MM. Percutaneous Intervention Before Coronary Artery Bypass Surgery Does Not Unfavorably Impact Survival: A Single-Center PropensityMatched Analysis. Ann Thorac Surg. 2016;102(6):1911-8. doi:10.1016/j.athoracsur.2016.07.046.

15. Parikh SV, de Lemos JA, Jessen ME, et al. Timing of in-hospital coronary artery bypass graft surgery for non-ST-segment elevation myocardial infarction patients results from the National Cardiovascular Data Registry ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines). JACC: Cardiovasc Interv. 2010;3(4):419-27. doi:10.1016/j.jcin.2010.01.012.