Mis-estimation of coronary lesions and rectification by SYNTAX score feedback for coronary revascularization appropriateness

Background::Imprecise interpretation of coronary angiograms was reported and resulted in inappropriate revascularization.Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery(SYNTAX)score is a comprehensive system to evaluate the complexity of the overall lesions.We hypothesized that a real-time SYNTAX score feedback from image analysts may rectify the mis-estimation and improve revascularization appropriateness in patients with stable coronary artery disease(CAD).Methods::In this single-center,historical control study,patients with stable CAD with coronary lesion stenosis≥50%were consecutively recruited.During the control period,SYNTAX scores were calculated by treating cardiologists.During the intervention period,SYNTAX scores were calculated by image analysts immediately after coronary angiography and were provided to cardiologists in real-time to aid decision-making.The primary outcome was revascularization deemed inappropriate by Chinese appropriate use criteria for coronary revascularization.Results::A total of 3245 patients were enrolled and assigned to the control group(08/2016-03/2017,n=1525)or the intervention group(03/2017-09/2017,n=1720).For SYNTAX score tertiles,17.9%patients were overestimated and 4.3%were underestimated by cardiologists in the control group.After adjustment,inappropriate revascularization significantly decreased in the intervention group compared with the control group(adjusted odds ratio[OR]:0.83;95%confidence interval[CI]:0.73-0.95;P=0.007).Both inappropriate percutaneous coronary intervention(adjusted OR:0.82;95%CI:0.74-0.92;P<0.001)and percutaneous coronary intervention utilization(adjusted OR:0.88;95%CI:0.79-0.98;P=0.016)decreased significantly in the intervention group.There was no significant difference in 1-year adverse cardiac events between the control group and the intervention group.Conclusions::Real-time SYNTAX score feedback significantly reduced inappropriate coronary revascularization in stable patients with CAD.Clinical trial registration::Nos.NCT03068858 and NCT02880605;https://www.clinicaltrials.gov.

Assessing the association of appropriateness of coronary revascularization and 1-year clinical outcomes for patients with stable coronary artery disease in China

Background:The Chinese appropriate use criteria(AUC)for coronary revascularization was released in 2016 to improve the use of coronary revascularization.This study aimed to evaluate the association between the appropriateness of coronary revascularization based on the Chinese AUC and 1-year outcomes in stable coronary artery disease(CAD)patients.Methods:We conducted a prospective,multi-center cohort study of stable CAD patients with coronary lesion stenosis≥50%.After the classification of appropriateness based on Chinese AUC,patients were categorized into the coronary revascularization group or the medical therapy group based on treatment received.The primary outcome was a composite of death,myocardial infarction,stroke,repeated revascularization,and ischemic symptoms with hospital admission.Results:From August 2016 to August 2017,6085 patients were consecutively enrolled.Coronary revascularization was associated with a lower adjusted hazard of 1-year major adverse cardiovascular and cerebrovascular events(MACCEs;hazard ratio[HR]:0.62;95%confidence interval[CI]:0.45-0.86;P=0.004)than medical therapy in patients with appropriate indications(n=1617).No significant benefit in 1-year MACCEs was found after revascularization compared to after medical therapy in patients with uncertain indications(n=2658,HR:0.81;95%CI:0.52-1.25;P=0.338)and inappropriate indications(n=1810,HR:0.80;95%CI:0.51-1.23;P=0.308).Conclusions:In patients with appropriate indications according to Chinese AUC,coronary revascularization was associated with significantly lower risk of MACCEs at 1 year.No benefit was found in coronary revascularization in patients with inappropriate indications.Our findings provide evidence for using Chinese AUC to guide clinical decision-making.

Surgical left atrial appendage occlusion in patients with atrial fibrillation undergoing mechanical heart valve replacement

Background:Surgical left atrial appendage occlusion(SLAAO)may be associated with a lower risk of thromboembolism in patientswith atrial fibrillation undergoing cardiac surgery.However,evidence regarding the effectiveness of SLAAO in patients undergoingmechanical heart valve replacement(MHVR)is lacking.Therefore,we aimed to evaluate the association between SLAAO and thecardiovascular outcomes in patients with atrial fibrillation undergoing MHVR.Methods:We retrospectively analyzed data for 497 patients with atrial fibrillation;27.6%of the patients underwent SLAAO,andthe remainder of the patients did not(No-SLAAO group).The primary outcome was a composite of ischemic stroke,systemicembolism,and all-cause mortality.Cumulative event-free survival rates were estimated using Kaplan-Meier curves,and weperformed multivariate Cox analyses to evaluate the association between SLAAO and outcomes.We used one-to-one propensityscore matching to balance patients’baseline characteristics,and analyzed 120 matching pairs.Results:Five patients died within 30 days postoperatively,and there were no significant differences between the two groupsregarding in-hospital complications(all P>0.05).After a median follow-up of 14 months,14 primary events occurred.Kaplan-Meier curves showed no difference in the cumulative incidence of freedom from the primary outcome(log-rank P=0.830),hemorrhagic events(log-rank P=0.870),and the secondary outcome(log-rank P=0.730),between the two groups.MultivariableCox proportional hazards regression analysis showed no association between SLAAO and any outcome(all P>0.05).Afterpropensity score matching,cardiopulmonary bypass time and aortic cross-clamp time,and the postoperative length of stay weresignificantly longer in the SLAAO group(all P<0.05);results were similar to the unadjusted analyses.Conclusions:Concomitant SLAAO and MHVR was associated with longer length of stay,and cardiopulmonary bypass time andaortic cross-clamp time,but was not associated with additional protective effects against thromboembolic events and mortalityduring the 14-month follow-up.