Influence of Pre-PTCA Strategy and Initial PTCA Result in
Patients With Multivessel Disease
The Bypass Angioplasty Revascularization Investigation (BARI)
Kevin E. Kip, PhD; Martial G. Bourassa, MD; Alice K. Jacobs, MD; Leonard Schwartz, MD;
Frederick Feit, MD; Edwin L. Alderman, MD; Bonnie H. Weiner, MD; Melvin B. Weiss, MD;
Mirle A. Kellett, Jr, MD; Barry L. Sharaf, MD; Alexios P. Dimas, MD; Robert H. Jones, MD;
George Sopko, MD; Katherine M. Detre, MD; for the BARI Investigators
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Background—In PTCA patients with multivessel coronary artery disease, incomplete revascularization (IR) is the result
of both pre-PTCA strategy and initial lesion outcome. The unique contribution of these components on long-term patient
outcome is uncertain.
Methods and Results—From the Bypass Angioplasty Revascularization Investigation (BARI), 2047 patients who
underwent first-time PTCA were evaluated. Before enrollment, all significant lesions were assessed by the PTCA
operator for clinical importance and intention to dilate. Complete revascularization (CR) was defined as successful
dilatation of all clinically relevant lesions. Planned CR was indicated in 65% of all patients. More lesions were intended
for PTCA in these patients compared with those with planned IR (2.8 versus 2.1). Successful dilatation of all intended
lesions occurred in 45% of patients with planned CR versus 56% with planned IR (P,0.001). In multivariable analysis,
planned IR (versus planned CR), initial lesions attempted (not all versus all intended lesions attempted), and initial lesion
outcome (not all versus all attempted lesions successful) were unrelated to 5-year risk of cardiac death or
death/myocardial infarction but were all independently related to risk of CABG.
Conclusions—Overall, a pre-PTCA strategy of IR in BARI-like patients appears comparable to a strategy of CR except
for a higher need for CABG. Whether the use of new devices may attenuate the elevated risk of CABG in patients with
multivessel disease and planned IR remains to be determined. (Circulation. 1999;100:910-917.)
Key Words: angioplasty n coronary disease n revascularization
T
he effect of incomplete revascularization (IR) on clinical
outcome in patients with multivessel coronary artery
disease (CAD) treated with PTCA remains unclear.1–12 Early
reports1–3 suggest higher rates of CABG and angina in
patients incompletely versus completely revascularized with
PTCA, whereas others, including those with adjustment for
differences in pretreatment clinical profiles,4,7 report modest
or no adverse effect associated with IR. Small patient cohorts
and different analytic techniques and definitions of complete
revascularization (CR) have contributed to the uncertainty.
Anatomic IR in patients with multivessel CAD can occur
for several reasons, including untreated chronic total occlusions considered not amenable to PTCA; untreated, less-thansevere coronary narrowings (ie, 50% to 69%); untreated
lesions supplying akinetic or dyskinetic left ventricular seg-
ments; and less frequently, unsuccessful lesion dilation.13
Thus, both pre-PTCA treatment strategy and initial outcome
of treated lesions determine the patient’s anatomic completeness of revascularization. Conceptually, when revascularization is anatomically incomplete, it can be subdivided by
functional adequacy or inadequacy (ie, revascularization of
all versus not all stenoses in arteries supplying viable myocardium), and this distinction appears to have prognostic
significance.9,10 Hence, investigation of the effect of IR on
clinical outcome requires consideration of pre-PTCA strategy, initial dilatation success, and functional significance of
the myocardial territory revascularized.
Here, we evaluate the relative contributions of pre-PTCA
strategy (planned CR versus planned IR), initial lesions
attempted (whether or not all planned lesions were attempt-
Received January 25, 1999; revision received June 1, 1999; accepted June 9, 1999.
From the Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pa (K.E.K., K.M.D); Montreal Heart Institute, Montreal, Canada (M.G.B.);
Boston Medical Center, Boston, Mass (A.K.J.); Toronto Hospital, Toronto, Canada (L.S.); New York University Medical Center, New York, NY (F.F.);
Stanford University Medical Center, Palo Alto, Calif (E.L.A.); University of Massachusetts Medical Center, Worcester, Mass (B.H.W.); New York
Medical College, Valhalla, NY (M.B.W.); Maine Medical Center, Portland, Me (M.A.K.); Rhode Island Hospital, Providence, RI (B.L.S.); Cleveland
Clinic Foundation, Cleveland, Ohio (A.D.); Duke University Medical Center, Durham, NC (R.H.J.); and the National Heart, Lung, and Blood Institute,
Bethesda, Md (G.S.).
Correspondence to Kevin E. Kip, PhD, University of Pittsburgh, Graduate School of Public Health, 130 DeSoto St, 127 Parran Hall, Pittsburgh, PA
15261. E-mail [email protected]
© 1999 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
910
Kip et al
Influence of Pre-PTCA Strategy and Initial Result
911
Figure 2. Patient subgroups according to lesion outcome and
pre-PTCA strategy.
Figure 1. Patient population showing study participants from
BARI randomized trial and clinically eligible, nonrandomized registry of patients who received PTCA as initial revascularization.
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ed), and initial lesion outcome on short- and long-term
clinical outcome in patients with multivessel disease.
Methods
Patient Population
A total of 2047 patients who underwent first-time PTCA were
considered. This included 900 of 904 patients who were assigned to
and received PTCA in the Bypass Angioplasty Revascularization
Investigation (BARI) randomized trial, a randomized study of 1829
patients comparing initial PTCA versus CABG.14,15 Also included
were 1147 of 1189 eligible patients who did not agree to participate
in the randomized trial but consented to be followed in an observational registry and received initial PTCA within 3 months of study
entry (Figure 1). Recruitment and selection criteria of BARI have
been described elsewhere.14 –16 Briefly, eligibility required clinically
severe angina or objective evidence of ischemia requiring revascularization, multivessel CAD suitable for both PTCA and CABG, and
informed consent. Ability to achieve CR was not required, although
the protocol required anticipated successful relief of the major areas
of ischemia. Patients were enrolled in 18 centers across North
America between August 1988 and August 1991.
Forty-six patients who received initial PTCA were excluded (4
randomized and 42 registry patients) because of incomplete angiographic data. A central radiological laboratory interpreted angiograms from patients in the randomized trial; however, the same
mechanism was not used in the observational registry. Therefore,
clinical site readings were used for all patients.
Angiographic Definitions
Angiographically significant lesions were defined as $50% stenoses
in a vessel $1.5 mm, as measured by electronic calipers.17 The
number of diseased vessels was determined from the 3 major
coronary perfusion territories (anterior, lateral, and inferoposterior)
supplied by a vessel with a significant lesion. Lesion complexity was
classified by use of American Heart Association/American College
of Cardiology consensus panel criteria.18 Flow distal to each stenosis
was defined by TIMI flow criteria.19 A reduction in stenosis of
$20% with residual stenosis of ,50% and TIMI grade 3 flow
defined successful lesion dilation.
Determination of Pre-PTCA Strategy and Initial
Completeness of Revascularization
Before patients entered the study, their angiograms were reviewed by
the PTCA operator to assess the clinical importance of each
significant lesion and its suitability for PTCA.20 Angiographically
significant lesions were judged as culprit (responsible, entirely or
partially, for the patient’s clinical syndrome), important (contributed
to patient’s ischemic syndrome), borderline (considered for revascularization incidental to treatment of culprit/important lesions), or
unimportant (territory too small or nonviable myocardium–ie, on the
basis of evidence of transmural infarction). For lesions considered
culprit, important, or borderline, the intention (yes versus no) to
perform PTCA was indicated. About 4% of all significant lesions
were not rated for clinical importance or intention. These lesions
were generally characterized as class C, excessively long or diffuse,
and were assumed to be unintended for PTCA.
CR was considered planned when all lesions deemed culprit,
important, or borderline were designated by the PTCA operator as
intended for revascularization. Otherwise, the patient had a prePTCA strategy of IR. Thus, the definition of planned CR refers to
functionally adequate revascularization. When CR was planned and
all intended lesions were successfully dilated, the patient was
considered to be completely revascularized.
Data Collection
Details of the initial PTCA and follow-up clinical events, including
procedural and long-term mortality, recurrence of angina, and
repeated revascularization, were recorded on standardized forms.
Resting ECGs were collected at study entry, before and after all
coronary revascularization procedures, at scheduled follow-up, and
for suspected myocardial infarction (MI) events. A central ECG
laboratory coded all Q-wave events. According to protocol, cardiac
enzymes were not used to define MI within 96 hours of revascularization.14,21 Cause of death was classified by an independent Mortality and Morbidity Classification Committee.
Statistical Analysis
The patient population was analyzed by a 332 design. The 3 group
components were determined from initial lesion outcome: (1) all
intended lesions were attempted and successful, (2) all intended
lesions were attempted but not all were successful, and (3) not all
intended lesions were attempted. Within these groups, patients were
dichotomized by pre-PTCA strategy (planned CR versus planned IR)
(Figure 2).
Initially, baseline clinical and angiographic characteristics were
compared separately within the 3 and 2 group components. Subsequently, in-hospital characteristics and complications were compared
by planned strategy (CR versus IR) within the 3 initial outcome
groups (from the above 332 design). Proportions were compared by
x2 analysis; mean differences in continuous variables were assessed
by Student’s t tests.
The Kaplan-Meier method was used to estimate 5-year clinical
event rates. Additionally, a subset of 1830 patients (89.4% of total
cohort) who did not experience in-hospital death, MI, or CABG at
the initial PTCA were analyzed separately. At the data freeze, 95%
of surviving patients had $4 years of follow-up; 67% had $5 full
years. Patients with ,5 years were censored at the last follow-up
date. Similarly, for estimates of cardiac mortality, deaths classified
as noncardiac were censored. Within the 3 initial outcome groups
(groups 1 through 3), the log-rank statistic was used to compare
hazard curves between patients with planned CR and those with
planned IR. Cox regression analysis22 was used to estimate the
independent contribution of planned IR (versus planned CR), lesions
attempted (not all versus all intended lesions attempted), and lesion
outcome (not all versus all attempted lesions successfully dilated) on
912
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August 31, 1999
TABLE 1. Baseline Angiographic Characteristics by Pre-PTCA Strategy and Initial
Lesion Outcome
Pre-PTCA Strategy
Initial Lesion Outcome
All Intended Lesions Attempted
Planned
CR
(n51331)
Planned
IR
(n5716)
All Successful
(n5994)
Not All Successful
(n5326)
Not All Intended
Lesions Attempted
(n5727)
65.0
35.0
48.6
15.9
35.5
Double (n51461)
73.2
26.8
52.6
16.0
31.4
Triple (n5586)
44.5
55.5
38.6
15.7
45.7
,4 (n51482)
72.6
27.4
54.9
14.7
30.4
$4 (n5565)
45.1
54.9
31.9
19.1
49.0
0 (n51859)
70.8
29.2
49.0
15.7
35.3
$1 (n5188)
8.0
92.0
44.7
18.1
37.2
0 (n51353)
76.1
23.9
50.9
14.8
34.3
$1 (n5694)
43.4
56.6
43.9
18.2
37.9
0 (n51342)
75.8
24.2
51.8
15.0
33.2
$1 (n5705)
44.5
55.5
42.4
17.7
39.9
No (n51318)
65.8
34.2
48.9
16.5
34.6
Yes (n5729)
63.6
36.4
48.0
14.8
37.2
,50% (n51514)
57.8
42.2
44.6
16.5
38.9
$50% (n5303)
67.3
32.7
49.5
15.3
35.3
Baseline Characteristic
Overall, % (n52047)
Vessel disease,*† %
Significant lesions,*† %
Significant diffuse lesions,* %
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Total occlusions,*‡ %
Class C lesions,*† %
Proximal LAD disease, %
Ejection fraction,§ %
Pre-PTCA Strategy,† %
CR (n51331)
IR (n5716)
100.0
0.0
44.7
15.3
40.1
0.0
100.0
55.7
17.2
27.1
Row percentages are displayed. Missing cases exist for ejection fraction.
For 2-group planned CR vs planned IR comparison, *P,0.001, §P,0.01. For 3-group initial lesion outcome
comparison, †P,0.001, ‡P,0.01.
5-year clinical outcome. A stepwise algorithm was used to adjust for
baseline clinical and angiographic variables associated with 5-year
clinical outcome. When the planned strategy and initial lesion
outcome variables did not step into the model, they were forced in at
the last stage of model development.
Results
Baseline Clinical Characteristics and Completeness
of Revascularization
Among the 3 columns of patients with planned CR (Figure 2),
595 (45%) had all intended lesions successfully dilated. This
compared with 399 patients (56%) with planned IR
(P,0.001). At baseline, patients with planned IR had a worse
clinical profile than patients with planned CR (data not
shown). This included older mean age (62.2 versus 60.9
years, P50.006) and history of MI (56% versus 50%,
P50.01), congestive heart failure (9% versus 5%, P50.002),
treated diabetes (20% versus 15%, P50.004), and peripheral
vascular disease (9% versus 6%, P50.02).
Baseline Angiographic Characteristics and
Completeness of Revascularization
Characteristics associated with planned IR included triplevessel disease, $4 significant lesions, diffuse lesions, presence of total occlusions or class C lesions, and poor ejection
fraction (Table 1, left). Most of these same factors were also
associated with failure to successfully dilate all intended
lesions (Table 1, right).
Initial Procedural Outcome
Overall, the mean numbers of intended and attempted lesions
were higher in patients with planned CR compared with those
with planned IR (2.8 versus 2.1 and 2.2 versus 1.8, respectively; Table 2). Among patients with all intended lesions
successfully dilated (Table 2, left), in-hospital death/Q-wave
MI and repeated revascularization were infrequent and were
attributed to postdilatation complications, including out-oflaboratory abrupt closure.
Among patients without all intended lesions successfully
dilated (Table 2, middle and right columns), in-laboratory
Kip et al
TABLE 2.
Influence of Pre-PTCA Strategy and Initial Result
913
Procedural Characteristics and In-Hospital Complications by Initial Lesion Outcome and Pre-PTCA Strategy
All Intended Lesions Attempted
All Successful
Not All Intended Lesions Attempted
Not All Successful
Procedural Characteristics and
In-Hospital Complications
Planned CR
(n5595)
Planned IR
(n5399)
Planned CR
(n5203)
Planned IR
(n5123)
Planned CR
(n5533)
Planned IR
(n5194)
Lesions intended (mean), n*†‡
2.4
1.7
2.9
2.3
3.1
2.7
Lesions attempted (mean), n*†‡
2.4
1.8
2.9
2.5
1.6
1.5
Class C or total occlusion attempted, %
18.5
15.8
31.5
26.8
19.0
19.6
Successfully dilated lesions (mean), n*†
2.4
1.8
1.7
1.3
1.2
1.1
3.9
3.5
13.8
14.6
10.5
12.9
Abrupt closure, %
In laboratory
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Out of laboratory
2.0
0.5
2.5
3.3
3.0
2.1
In-hospital death, %
0.3
0.0
1.0
1.6
2.1
0.5
In-hospital Q-wave MI, %
1.3
1.0
3.5
4.1
3.6
3.6
In-hospital death/Q-wave MI, %
1.7
1.0
3.9
5.7
5.3
4.1
CABG,§ %
1.2
2.0
9.9
18.7
17.8
16.5
Repeat PTCA, %
3.0
3.0
4.4
4.1
6.0
3.1
Mean lesions intended, attempted, and successful refers to significant lesions only.
For “all successful” comparison (planned CR vs planned IR), *P,0.001.
For “not all successful” comparison (planned CR vs planned IR), †P,0.001, §P,0.05.
For “not all attempted” comparison (planned CR vs planned IR), ‡P,0.001.
abrupt closure occurred $10% in each group but not differ by
whether or not CR was planned. Therefore, the reason that not
all intended lesions were attempted in some patients (Table 2,
right) was not attributed predominantly to acute vessel
occlusion.
Finally, among patients with all intended lesions attempted
but not all successful (Table 2, middle), those with planned
CR had a lower incidence of in-hospital CABG than those
with planned IR (9.9% versus 18.7%). In contrast, the
incidence of in-hospital CABG among patients without all
intended lesions attempted (Table 2, right) did not differ by
pre-PTCA strategy but was frequent ('17%).
Finally, as shown in Table 3 and Figure 4A, 5-year
incidence of CABG was markedly higher in patients with
planned IR. This excess risk occurred regardless of whether
or not all intended lesions were attempted and successful and
held true among patients free of initial in-hospital death/MI/
CABG (Figure 4B). Most CABGs were performed in the first
year of follow-up, with the excess risk associated with
planned IR observed within the first 2 years. Roughly 70% of
patients who underwent CABG had unstable angina and/or an
urgent or emergent revascularization priority (regardless of
whether CR was planned and among both randomized and
registry patients).
Long-Term Clinical Outcome
Multivariable Analysis
Among patients with all intended lesions successfully dilated
(Table 3, left), the 5-year incidence of death, cardiac death,
and death/MI was similar regardless of whether or not CR
was planned. However, the prevalence of angina at 5 years
was higher in patients with planned IR (20.0% versus 14.8%,
P50.04).
In patients without all intended lesions attempted (Table 3,
right), 5-year mortality was higher in patients with planned IR
compared with those planned CR (14.2% versus 8.9%,
P50.04). This higher mortality was also observed in patients
free of in-hospital death, MI, or CABG at the index PTCA
(15.1% versus 7.1%, P50.002). A similar trend was observed
in these same patients for cardiac mortality (7.8% versus
3.9%, P50.06). Among patients with all intended lesions
attempted but not successfully dilated (Table 3, middle), there
was a suggestion of higher 5-year death and death/Q wave MI
(Figure 3) in patients with planned IR compared with those
with planned CR (16.8% versus 9.6% and 25.9% versus
17.5%, respectively; P50.06 for both comparisons).
Pre-PTCA strategy (planned IR versus planned CR), lesions
attempted (not all versus all intended lesions attempted), and
lesion outcome (not all versus all attempted lesions successful) were not independently associated with 5-year risk of
cardiac death or death/Q-wave MI (Figure 5). However, the
point estimate for planned IR and risk of death approached
significance (relative risk [RR], 1.36; 95% CI, 1.00 to 1.84;
P50.05). In contrast, 5-year risk of CABG was independently associated with planned IR (RR, 1.27; 95% CI, 1.01 to
1.60; P50.04), not attempting all intended lesions (RR, 1.50;
95% CI, 1.22 to 1.85; P50.0001), and unsuccessful dilatation
of all attempted lesions (RR, 1.48; 95% CI, 1.20 to 1.84;
P50.0003).
Discussion
In patients with multivessel CAD treated with PTCA, IR
occurs frequently and is the result of both pre-PTCA strategy
and initial lesion outcome. These components, coupled with
varying definitions and the distinction between anatomic
914
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TABLE 3.
August 31, 1999
Kaplan-Meier 5-Year Event Rates by Initial Lesion Outcome and Pre-PTCA Strategy
All Intended Lesions Attempted
All Successful
Not All Intended Lesions Attempted
Not All Successful
Planned CR
(n5595)
Planned IR
(n5399)
Planned CR
(n5203)
Planned IR
(n5123)
Planned CR
(n5533)
Planned IR
(n5194)
All patients*
9.2
11.9
10.5
15.1
8.9
14.2
Patients without in-hospital death/MI/CABG†
9.0
12.2
9.6
16.8
7.1
15.1
All patients
5.3
5.6
7.2
8.4
5.7
7.5
Patients without in-hospital death/MI/CABG
5.1
5.8
6.4
8.5
3.9
7.8
All patients
14.8
16.9
17.5
25.9
18.8
20.4
Patients without in-hospital death/MI/CABG
13.5
16.3
15.3
24.3
15.3
18.9
All patients§
14.8
20.0
16.5
22.6
18.0
18.9
Patients without in-hospital death/MI/CABG
14.8
19.5
16.5
23.8
19.6
21.5
All patients§¶
17.8
23.3
32.1
44.2
38.7
47.4
Patients without in-hospital death/MI/CABG‡
16.5
21.7
24.4
31.6
25.3
36.8
All patients*
37.3
36.1
35.6
35.9
32.7
23.1
Patients without in-hospital death/MI/CABG
36.6
35.9
35.1
40.4
35.0
26.8
5-Year Clinical Event
Death
Cardiac death
Death/Q-wave MI
Angina‡
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CABG
Repeat PTCA
For “all successful” comparison (planned CR vs planned IR), §P,0.05.
For “not all successful” comparison (planned CR vs planned IR), ¶P,0.01.
For “not all attempted” comparison (planned CR vs planned IR), †P,0.01, *P,0.05.
‡Crude rate rather than Kaplan-Meier estimate.
versus functional CR, have led to numerous yet equivocal
reports on the influence of CR on clinical outcome.1– 4,7 Among
.2000 BARI patients treated with first-time PTCA during 1988
through 1991, we evaluated the relative contribution of prePTCA strategy (planned CR versus planned IR) and initial lesion
outcome on clinical outcome. We considered a functional rather
than anatomic definition of planned CR.
Initial PTCA Outcome
Overall, about one third of all patients had a planned strategy
of IR, and not unexpectedly, these patients had a higher
prevalence of triple-vessel disease and more significant stenoses. Patients with planned CR were less likely to have all
intended lesions successfully dilated than patients with
planned IR. This lower rate of total angiographic success was
probably the result of 2 factors. First, patients with planned
CR had, on average, more lesions intended for PTCA. Thus,
there was additional opportunity for failure of $1 lesion.
Second, although patients with planned CR had overall less
extensive CAD than patients with planned IR, more lesions
were intended and attempted in this group. This suggests a
more aggressive approach, perhaps including lesions difficult
to treat with conventional PTCA. The fact that about one
fourth of all patients with planned CR had $1 class C lesion
supports this contention. Previous studies have reported the
difficulty in achieving CR in attempts to revascularize
chronic total occlusions.6,23
When all planned lesions were not attempted or successfully dilated, the incidence of abrupt closure and Q-wave MI
was similar by pre-PTCA strategy. Thus, incident abrupt
closure, which precipitated a substantial proportion of the
major in-hospital complications, was not influenced by
whether or not CR was planned. Moreover, abrupt closure
alone was not the primary reason why not all intended lesions
were attempted. Thus, other factors, such as suboptimal result
(but not acute occlusion) and poor patient tolerance of PTCA,
may be important contributors to the reason that less revascularization is attempted compared with what is initially
intended.
Long-Term Clinical Outcome
In unadjusted analyses, planned IR (versus planned CR) was
associated with higher mortality and a trend toward higher
cardiac mortality in patients in whom all intended lesions
were not attempted and/or successfully dilated. However,
after statistical adjustment, 5-year risk of cardiac death and
death/MI was similar in patients by pre-PTCA strategy. These
results are consistent with reports suggesting comparable
mid-term survival with and without CR after PTCA.4,5,7 Our
data suggest that clinically appropriate use of planned IR by
experienced angioplasty operators is a reasonable strategy in
patients with multivessel disease.
However, there was still an excess independent risk of
CABG in patients with planned IR and among those with a
Kip et al
Influence of Pre-PTCA Strategy and Initial Result
915
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Figure 3. Plots of 5-year death/Q-wave MI by lesion outcome and pre-PTCA strategy for all patients (A) and for patients free of initial
in-hospital death, MI, or CABG (B).
suboptimal result. These findings support previous reports1,3,4,6,8 and the contention that IR, whether by intention or
suboptimal PTCA result, is associated with higher risk of
CABG. These findings persist even among patients initially
free of major in-hospital complications and are particularly
prominent in the first year after PTCA. In essence, among
patients with multivessel CAD not suitable for CR via PTCA,
the angioplasty operator may ultimately be more inclined to
“give up” and triage to CABG those patients with subsequent
need for repeated revascularization.
Study Limitations
All PTCA procedures were performed in 1988 through 1991
without the use of new devices, including stents. The excess
risk of CABG observed in relation to both pre-PTCA strategy
and suboptimal result with conventional PTCA might have
been attenuated had stents been used and similarly may be
less prominent today.
Our definition of CR is study specific and based on
angiographic criteria and PTCA operator judgments of the
importance and suitability of significant stenoses for
PTCA. Possibly, a more physiologically relevant definition of CR, such as successful treatment of lesions $70%
stenosis (as opposed to $50%), could have been used.
Similarly, quantitative evaluation of patient atherosclerotic
burden was not derived from a core laboratory. There may
have been site variability in determining which patients
were intended to undergo and those who achieved CR.
With random variation within centers assumed, the misclassification of planned and achieved CR would likely be
nondifferential and would tend to bias study results toward
the null.
Finally, although patients from the randomized trial and
observational registry met the same clinical eligibility criteria, differences exist between the cohorts. Specifically, registry patients were more often white; were more educated
with a higher self-rated quality of life; and had a less frequent
history of MI, diabetes, and smoking.24 These differences,
however, do not appear to be influential here because,
remarkably, the percentages of patients with planned CR
(65%) and those with actual CR achieved (29%) were
identical between the 2 cohorts. This suggests that PTCA
operators were equally motivated to achieve CR in both
populations.
Conclusions
Among .2000 patients with multivessel CAD treated with
first-time PTCA, about one third had a pre-PTCA strategy of
functional IR, '50% had all intended lesions attempted and
successfully dilated, and only 29% were completely revascularized. Triple-vessel disease, $4 significant lesions, and
difficult lesions for conventional PTCA (ie, class C lesions)
were associated with planned IR and suboptimal PTCA.
Abrupt closure strongly precipitated major in-hospital com-
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August 31, 1999
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Figure 4. Plots of 5-year CABG by lesion outcome and pre-PTCA strategy for all patients (A) and for patients free of in-hospital death,
MI, or CABG (B).
plications but was unrelated to whether or not CR was
planned. In multivariable analysis, planned IR and failure to
successfully dilate all intended lesions were unrelated to
long-term risk of cardiac death or cardiac death/MI. However, risk of CABG, particularly within the first year follow-
ing PTCA, was higher in patients with planned IR and among
those with a suboptimal initial result.
Overall, a pre-PTCA strategy of IR in BARI-like patients
appears comparable to a strategy of CR, except for a higher
need for CABG. Whether or not the use of new devices may
Figure 5. Plot of 5-year adjusted relative
risks of pre-PTCA strategy and lesion
outcome variables on clinical outcomes
(patients free of initial in-hospital death,
MI, or CABG). Bullets depict relative
risks; dashed lines, 95% CIs. Q-MI indicates Q-wave MI.
Kip et al
attenuate this elevated risk of CABG in similar patients
remains to be determined.
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Circulation. 1999;100:910-917
doi: 10.1161/01.CIR.100.9.910
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