Impact of the presence and extent of incomplete angiographic revascularization after percutaneous coronary intervention in acute coronary syndromes

The acute catheterization and urgent intervention triage strategy (ACUITY) trial

Gregg F. Rosner, Ajay J. Kirtane, Philippe Genereux, Alexandra J. Lansky, Ecaterina Cristea, Bernard J. Gersh, Giora Weisz, Helen Parise, Martin Fahy, Roxana Mehran, Gregg W. Stone

Research output: Contribution to journalArticle

93 Citations (Scopus)

Abstract

Background-The clinical significance of incomplete coronary revascularization (ICR) after percutaneous coronary intervention in patients with acute coronary syndromes is unknown. Methods and Results-We performed quantitative angiography of the entire coronary tree in 2954 patients with acute coronary syndromes in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. ICR was variably defined if any lesion with diameter stenosis (DS) cutoffs ranging from ≥30% to ≥70% with reference vessel diameter 2.0 mm remained after percutaneous coronary intervention. The primary outcome was 1-year composite rate of major adverse cardiac events (death, myocardial infarction, or ischemia-driven unplanned revascularization). With the use of DS cutoffs ≥30%, ≥40%, ≥50%, ≥60%, and ≥70%, the prevalence of ICR after percutaneous coronary intervention was ≥75%, ≥55%, ≥37%, ≥25%, and ≥17%, respectively. The 1-year major adverse cardiac event rate was increased among patients with ICR using all of the DS cutoffs. ICR (≥50% DS) was associated with higher 1-year rates of myocardial infarction (12.0% versus 8.2%; hazard ratio, 1.50; 95% confidence interval, 1.18-1.89; P=0.0007) and ischemia-driven unplanned revascularization (15.7% versus 10.2%; hazard ratio, 1.58; 95% confidence interval, 1.28-1.96; P<0.0001), with a trend toward increased mortality (3.1% versus 2.2%; hazard ratio, 1.43; 95% confidence interval, 0.90-2.27; P=0.13). By multivariable analysis, ICR (50% DS) was an independent predictor of 1-year major adverse cardiac events (hazard ratio, 1.36; 95% confidence interval, 1.12-1.64; P=0.002). The impact of ICR on major adverse cardiac events was similar regardless of chronic total occlusion presence, but it was more pronounced with a greater number of nonrevascularized lesions. Conclusions-Depending on the threshold of percent DS, ICR was present in 17% to 75% of patients with acute coronary syndromes after percutaneous coronary intervention. Regardless of the threshold, ICR was strongly associated with 1-year myocardial infarction, ischemia-driven unplanned revascularization, and major adverse cardiac events. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.

Original languageEnglish (US)
Pages (from-to)2613-2620
Number of pages8
JournalCirculation
Volume125
Issue number21
DOIs
StatePublished - May 29 2012
Externally publishedYes

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Triage
Percutaneous Coronary Intervention
Acute Coronary Syndrome
Catheterization
Pathologic Constriction
Confidence Intervals
Myocardial Infarction
Myocardial Ischemia
Coronary Stenosis
Coronary Angiography
Ischemia
Clinical Trials
Mortality

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Rosner, Gregg F. ; Kirtane, Ajay J. ; Genereux, Philippe ; Lansky, Alexandra J. ; Cristea, Ecaterina ; Gersh, Bernard J. ; Weisz, Giora ; Parise, Helen ; Fahy, Martin ; Mehran, Roxana ; Stone, Gregg W. / Impact of the presence and extent of incomplete angiographic revascularization after percutaneous coronary intervention in acute coronary syndromes : The acute catheterization and urgent intervention triage strategy (ACUITY) trial. In: Circulation. 2012 ; Vol. 125, No. 21. pp. 2613-2620.
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title = "Impact of the presence and extent of incomplete angiographic revascularization after percutaneous coronary intervention in acute coronary syndromes: The acute catheterization and urgent intervention triage strategy (ACUITY) trial",
abstract = "Background-The clinical significance of incomplete coronary revascularization (ICR) after percutaneous coronary intervention in patients with acute coronary syndromes is unknown. Methods and Results-We performed quantitative angiography of the entire coronary tree in 2954 patients with acute coronary syndromes in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. ICR was variably defined if any lesion with diameter stenosis (DS) cutoffs ranging from ≥30{\%} to ≥70{\%} with reference vessel diameter 2.0 mm remained after percutaneous coronary intervention. The primary outcome was 1-year composite rate of major adverse cardiac events (death, myocardial infarction, or ischemia-driven unplanned revascularization). With the use of DS cutoffs ≥30{\%}, ≥40{\%}, ≥50{\%}, ≥60{\%}, and ≥70{\%}, the prevalence of ICR after percutaneous coronary intervention was ≥75{\%}, ≥55{\%}, ≥37{\%}, ≥25{\%}, and ≥17{\%}, respectively. The 1-year major adverse cardiac event rate was increased among patients with ICR using all of the DS cutoffs. ICR (≥50{\%} DS) was associated with higher 1-year rates of myocardial infarction (12.0{\%} versus 8.2{\%}; hazard ratio, 1.50; 95{\%} confidence interval, 1.18-1.89; P=0.0007) and ischemia-driven unplanned revascularization (15.7{\%} versus 10.2{\%}; hazard ratio, 1.58; 95{\%} confidence interval, 1.28-1.96; P<0.0001), with a trend toward increased mortality (3.1{\%} versus 2.2{\%}; hazard ratio, 1.43; 95{\%} confidence interval, 0.90-2.27; P=0.13). By multivariable analysis, ICR (50{\%} DS) was an independent predictor of 1-year major adverse cardiac events (hazard ratio, 1.36; 95{\%} confidence interval, 1.12-1.64; P=0.002). The impact of ICR on major adverse cardiac events was similar regardless of chronic total occlusion presence, but it was more pronounced with a greater number of nonrevascularized lesions. Conclusions-Depending on the threshold of percent DS, ICR was present in 17{\%} to 75{\%} of patients with acute coronary syndromes after percutaneous coronary intervention. Regardless of the threshold, ICR was strongly associated with 1-year myocardial infarction, ischemia-driven unplanned revascularization, and major adverse cardiac events. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.",
author = "Rosner, {Gregg F.} and Kirtane, {Ajay J.} and Philippe Genereux and Lansky, {Alexandra J.} and Ecaterina Cristea and Gersh, {Bernard J.} and Giora Weisz and Helen Parise and Martin Fahy and Roxana Mehran and Stone, {Gregg W.}",
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Impact of the presence and extent of incomplete angiographic revascularization after percutaneous coronary intervention in acute coronary syndromes : The acute catheterization and urgent intervention triage strategy (ACUITY) trial. / Rosner, Gregg F.; Kirtane, Ajay J.; Genereux, Philippe; Lansky, Alexandra J.; Cristea, Ecaterina; Gersh, Bernard J.; Weisz, Giora; Parise, Helen; Fahy, Martin; Mehran, Roxana; Stone, Gregg W.

In: Circulation, Vol. 125, No. 21, 29.05.2012, p. 2613-2620.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Impact of the presence and extent of incomplete angiographic revascularization after percutaneous coronary intervention in acute coronary syndromes

T2 - The acute catheterization and urgent intervention triage strategy (ACUITY) trial

AU - Rosner, Gregg F.

AU - Kirtane, Ajay J.

AU - Genereux, Philippe

AU - Lansky, Alexandra J.

AU - Cristea, Ecaterina

AU - Gersh, Bernard J.

AU - Weisz, Giora

AU - Parise, Helen

AU - Fahy, Martin

AU - Mehran, Roxana

AU - Stone, Gregg W.

PY - 2012/5/29

Y1 - 2012/5/29

N2 - Background-The clinical significance of incomplete coronary revascularization (ICR) after percutaneous coronary intervention in patients with acute coronary syndromes is unknown. Methods and Results-We performed quantitative angiography of the entire coronary tree in 2954 patients with acute coronary syndromes in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. ICR was variably defined if any lesion with diameter stenosis (DS) cutoffs ranging from ≥30% to ≥70% with reference vessel diameter 2.0 mm remained after percutaneous coronary intervention. The primary outcome was 1-year composite rate of major adverse cardiac events (death, myocardial infarction, or ischemia-driven unplanned revascularization). With the use of DS cutoffs ≥30%, ≥40%, ≥50%, ≥60%, and ≥70%, the prevalence of ICR after percutaneous coronary intervention was ≥75%, ≥55%, ≥37%, ≥25%, and ≥17%, respectively. The 1-year major adverse cardiac event rate was increased among patients with ICR using all of the DS cutoffs. ICR (≥50% DS) was associated with higher 1-year rates of myocardial infarction (12.0% versus 8.2%; hazard ratio, 1.50; 95% confidence interval, 1.18-1.89; P=0.0007) and ischemia-driven unplanned revascularization (15.7% versus 10.2%; hazard ratio, 1.58; 95% confidence interval, 1.28-1.96; P<0.0001), with a trend toward increased mortality (3.1% versus 2.2%; hazard ratio, 1.43; 95% confidence interval, 0.90-2.27; P=0.13). By multivariable analysis, ICR (50% DS) was an independent predictor of 1-year major adverse cardiac events (hazard ratio, 1.36; 95% confidence interval, 1.12-1.64; P=0.002). The impact of ICR on major adverse cardiac events was similar regardless of chronic total occlusion presence, but it was more pronounced with a greater number of nonrevascularized lesions. Conclusions-Depending on the threshold of percent DS, ICR was present in 17% to 75% of patients with acute coronary syndromes after percutaneous coronary intervention. Regardless of the threshold, ICR was strongly associated with 1-year myocardial infarction, ischemia-driven unplanned revascularization, and major adverse cardiac events. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.

AB - Background-The clinical significance of incomplete coronary revascularization (ICR) after percutaneous coronary intervention in patients with acute coronary syndromes is unknown. Methods and Results-We performed quantitative angiography of the entire coronary tree in 2954 patients with acute coronary syndromes in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. ICR was variably defined if any lesion with diameter stenosis (DS) cutoffs ranging from ≥30% to ≥70% with reference vessel diameter 2.0 mm remained after percutaneous coronary intervention. The primary outcome was 1-year composite rate of major adverse cardiac events (death, myocardial infarction, or ischemia-driven unplanned revascularization). With the use of DS cutoffs ≥30%, ≥40%, ≥50%, ≥60%, and ≥70%, the prevalence of ICR after percutaneous coronary intervention was ≥75%, ≥55%, ≥37%, ≥25%, and ≥17%, respectively. The 1-year major adverse cardiac event rate was increased among patients with ICR using all of the DS cutoffs. ICR (≥50% DS) was associated with higher 1-year rates of myocardial infarction (12.0% versus 8.2%; hazard ratio, 1.50; 95% confidence interval, 1.18-1.89; P=0.0007) and ischemia-driven unplanned revascularization (15.7% versus 10.2%; hazard ratio, 1.58; 95% confidence interval, 1.28-1.96; P<0.0001), with a trend toward increased mortality (3.1% versus 2.2%; hazard ratio, 1.43; 95% confidence interval, 0.90-2.27; P=0.13). By multivariable analysis, ICR (50% DS) was an independent predictor of 1-year major adverse cardiac events (hazard ratio, 1.36; 95% confidence interval, 1.12-1.64; P=0.002). The impact of ICR on major adverse cardiac events was similar regardless of chronic total occlusion presence, but it was more pronounced with a greater number of nonrevascularized lesions. Conclusions-Depending on the threshold of percent DS, ICR was present in 17% to 75% of patients with acute coronary syndromes after percutaneous coronary intervention. Regardless of the threshold, ICR was strongly associated with 1-year myocardial infarction, ischemia-driven unplanned revascularization, and major adverse cardiac events. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.

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