Heavily calcified lesions confer long-term mortality; PCI, CABG outcomes similar
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In patients with three-vessel CAD and/or left main disease, those with heavily calcified lesions had elevated long-term mortality risk, which did not vary by assignment to PCI or CABG, according to new data from the SYNTAXES study.
The SYNTAXES study is an extended follow-up of patients from the SYNTAX trial who had three-vessel CAD and/or left main disease and were randomly assigned to undergo PCI or CABG.
For the present analysis of 1,800 patients (mean age, 64 years; 77% men), researchers compared 10-year survival rates between the 532 patients who had at least one heavily calcified lesion (HCL) and the others who did not.
Long-term mortality
Crude 10-year mortality rates were higher in those with at least one HCL than in those without any (36.4% vs. 22.3%; HR = 1.79; 95% CI, 1.49-2.16; P < .001), Hideyuki Kawashima, MD, from National University of Ireland Galway, and colleagues wrote.
After adjustment, HCLs still independently predicted 10-year mortality (adjusted HR = 1.36; 95% CI, 1.09-1.69; P = .006), the researchers wrote.
In patients with at least one HCL, there was no difference in 10-year mortality between those assigned PCI and those assigned CABG (PCI, 34%; CABG, 39%; HR = 0.85; 95% CI, 0.64-1.13; P = .264), in contrast to patients with no HCL, for whom CABG was associated with better 10-year mortality rates (PCI, 26%; CABG, 18.8%; HR = 1.44; 95% CI, 1.14-1.83; P = .003; P for interaction = .005), according to the researchers.
“At 10-year follow-up, the presence of heavy calcification was an independent predictor of
mortality, with a similar prognosis following PCI or CABG,” Kawashima and colleagues wrote. “Whether HCL require special consideration when deciding the mode of revascularization beyond their current contribution to the anatomical SYNTAX score deserves further evaluation.”
Lack of CABG benefit
In a related editorial, Usman Baber, MD, associate professor of medicine and director of interventional cardiology and of the cardiac catheterization laboratory at the University of Oklahoma Health Sciences Center, wrote the lack of benefit of CABG in high-risk patients with heavy calcification was unexpected.
“First, dense coronary calcification may introduce technical challenges with respect to achieving an adequate vascular anastomosis and calcific target lesions are a common reason for incomplete surgical revascularization,” he wrote. “Moreover, HCL located in the distal vasculature may attenuate the potential benefits of a more proximal surgical bypass. Although not directly assessed, aortic calcification is also more commonly observed with coronary artery calcium and is a strong correlate of adverse outcomes after CABG. Notwithstanding the potential direct effects of coronary calcification, a second and perhaps more plausible explanation for the muted benefit of CABG is the burden of both extracardiac and noncardiac morbidity among such patients. For example, both peripheral vascular disease and chronic obstructive pulmonary disease were significantly more common among those with HCL and each emerged as an independent predictor of mortality.”
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