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Aggressive revascularization plus medical therapy best for CTO, collateral circulation
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CABG or PCI plus medical therapy was associated with reduced cardiac death and MACE compared with medical therapy alone in patients with coronary chronic total occlusion and well-developed collateral circulation.
Researchers evaluated long-term clinical outcomes in 738 consecutive patients with at least one CTO detected on coronary angiography, symptomatic angina and/or a positive functional ischemia study and Rentrop grade 3 collateral flow who were enrolled in the retrospective Samsung Medical Center CTO registry from March 2003 to February 2012. Of those, 236 received antiplatelet therapy with aspirin or clopidogrel, at least one antianginal medication and a high-dose statin with or without ezetimibe (Zetia, Merck) and 502 underwent PCI with a drug-eluting stent (n = 332) or CABG (n = 170) in addition to medical therapy.
Median follow-up was 42 months. Compared with medical therapy alone, revascularization was associated with less cardiac death (HR = 0.29; 95% CI, 0.15-0.58), all-cause death (HR = 0.44; 95% CI, 0.27-0.71), MACE including cardiac death, MI and repeat revascularization (HR = 0.32; 95% CI, 0.21-0.49) and repeat revascularization (HR = 0.38; 95% CI, 0.23-0.63), according to multivariate analysis. The incidence of MI was similar between revascularization and medical therapy alone (HR = 1.04; 95% CI, 0.16-6.8).
Results of a propensity score-matched analysis indicated similar results.
In subgroup analyses, the prevalence of repeat revascularization (P < .01) and MACE (P = .03) was significantly higher for patients who underwent PCI vs. CABG, after adjustment for diabetes, left ventricular ejection fraction and SYNTAX score, but the incidence of cardiac death, all-cause death and MI was similar between the revascularization groups.
“Based on our results, revascularization may be recommended as an initial treatment in patients with CTO and well-developed collateral circulation. A large-scale randomized trial is needed to confirm these findings,” the researchers concluded. – by Rob Volansky
Disclosure: The researchers report no relevant financial disclosures.
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