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Death (After Percutaneous Coronary Intervention) Is No Longer What It Used to Be

2014; Lippincott Williams & Wilkins; Volume: 129; Issue: 12 Linguagem: Inglês

10.1161/circulationaha.114.008492

1524-4539

Philippe Gabríel Steg, Adrian Cheong,

Antiplatelet Therapy and Cardiovascular Diseases

HomeCirculationVol. 129, No. 12Death (After Percutaneous Coronary Intervention) Is No Longer What It Used to Be Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBDeath (After Percutaneous Coronary Intervention) Is No Longer What It Used to Be Philippe Gabriel Steg, MD and Adrian Piers Cheong, MD Philippe Gabriel StegPhilippe Gabriel Steg From Université Paris-Diderot, DHU FIRE, Paris, France (P.G.S.); Hôpital Bichat, Paris, France (P.G.S., A.P.C.); INSERM U-1148, Paris, France (P.G.S.); NHLI, Imperial College, ICMS, Royal Brompton Hospital, London, UK (P.G.S.); Prince of Wales Hospital, Hong Kong, China (A.P.C.); and The Chinese University of Hong Kong, Hong Kong, China (A.P.C.). and Adrian Piers CheongAdrian Piers Cheong From Université Paris-Diderot, DHU FIRE, Paris, France (P.G.S.); Hôpital Bichat, Paris, France (P.G.S., A.P.C.); INSERM U-1148, Paris, France (P.G.S.); NHLI, Imperial College, ICMS, Royal Brompton Hospital, London, UK (P.G.S.); Prince of Wales Hospital, Hong Kong, China (A.P.C.); and The Chinese University of Hong Kong, Hong Kong, China (A.P.C.). Originally published10 Feb 2014https://doi.org/10.1161/CIRCULATIONAHA.114.008492Circulation. 2014;129:1267–1269Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 25, 2014: Previous Version 1 Percutaneous coronary intervention (PCI) has revolutionized the management of coronary artery disease.1 Its main goals are to improve the quantity and sometimes the quality of life by reducing mortality and nonfatal outcomes and by improving symptoms. Although these goals were clearly achieved when PCI was applied to the treatment of acute coronary syndromes,2,3 there is still uncertainty about the prognostic benefits of PCI in patients with stable coronary artery disease: Whereas PCI clearly improves angina symptoms, its benefits on clinical outcomes remain debated and may occur only if patients are at sufficient risk (because of extensive myocardial ischemia or because the amount of jeopardized myocardium is large enough).4–6Article see p 1286In this issue, Spoon et al7 report changes in long-term mortality after PCI over nearly 20 years. This study examined 19 077 patients who underwent PCI at the Mayo Clinic in Rochester, MN, and were discharged alive. It spans 3 distinct 6-year periods: the plain old balloon angioplasty era in the early 1990s, the bare metal stent era in the late 1990s, and the drug-eluting stent era in the 2000s. The study records survivals up to 5 years after the procedure, with a detailed description of the patients' characteristics and indications for PCI, as well as careful analysis and categorization of the causes of death.In this study, a change in patient characteristics over time was found: PCI was performed in increasingly older patients, with an increasing prevalence of noncardiac comorbidities. In parallel, there was a clear increase in the use of evidence-based therapies for secondary prevention. In-hospital mortality decreased for patients with stable angina but not for patients with acute coronary syndrome. Interestingly, the long-term postdischarge mortality appeared consistently slightly higher in the more recent era compared with older periods, but the most striking observation is a shift in long-term mortality from predominantly cardiac to noncardiac causes as a result of a decrease in cardiac deaths over time (from 9.8% to 7.4% and 6.6% at 5 years; P<0.001) and a parallel increase in noncardiac deaths (from 7.1% to 8.5% and 11.2%; P<0.001) This resulted in the astonishing observation that in the 2000s noncardiac mortality accounted for the majority of postdischarge deaths after PCI. The authors performed detailed sensitivity analyses according to age, geographic location vis-á-vis the institution, major risk factors, indication for PCI, and extent of coronary artery disease and were able to document that these observations are robust and that, after adjustment for baseline risk, there was no change in noncardiac mortality over the 3 time periods but a 50% decline in cardiac mortality, driven largely by a reduction in fatal myocardial infarction/sudden death but without change in heart failure–related deaths.The authors should be congratulated not only for achieving comprehensive long-term follow-up of this large cohort but also for their astute observations, which have far-ranging implications. Nevertheless, there are a number of potential caveats to this study. First, it was performed in a single center, and replication is important to assess the external validity of the findings. However, the population analyzed is large and reflects the broad indications of PCI performed in "all-comers." Likewise, although the diagnostic criteria for ST-segment–elevation myocardial infarction have remained stable, the tests and criteria used for defining and identifying patients with non–ST-segment acute coronary syndromes or stable coronary artery disease have evolved over time (with availability of increasingly sensitive tests). This could account for some changes in outcomes over time; the availability of more sensitive diagnostic tests would be expected to identify a population at lower risk of cardiovascular mortality.It is possible that we have gotten better at selecting patients for coronary angiography and PCI through better screening that incorporates patients' cardiovascular risk profiles, symptoms, cardiac biomarkers, and noninvasive test results. This could explain the findings of more extensive coronary artery disease and of a higher prevalence of cardiovascular risk factors in patients undergoing invasive procedures in recent periods in this study. The in-hospital mortality for stable angina PCI has fallen, likely reflecting temporal improvement in interventional techniques. However, in-hospital mortality for patients with acute coronary syndrome remained the same. The higher risk of these patients, in addition to their higher comorbidity load, probably negated the positive impact of improved procedural technique and adjuvant therapies.The decrease in long-term cardiac mortality is likely explained not only by improved procedural techniques and adjunctive therapies but, more important, by the increase in the use of effective evidence-based medical therapy for secondary prevention, relying (in addition to lifestyle modifications) on antiplatelet agents, angiotensin-converting enzyme inhibitors, and statins.8–11 The impact of these treatments on cardiovascular outcomes is well documented both in stable patients with coronary artery disease 12 and after acute coronary syndrome.13,14 In the present report, the use of angiotensin-converting enzyme inhibitors on discharge increased from 19% to 63% and that of lipid-lowering drugs from 25% to 90%. This underscores the importance of continued efforts for implementation of evidence-based therapies in patients undergoing PCI. In that respect, it is disturbing that, in recent analyses of patients undergoing PCI in the United States, a substantial proportion of patients fail to receive proper evidence-based medical therapy.15Although long-term cardiovascular mortality after PCI has decreased steadily over time, this decrease is related mostly to reductions in sudden death and fatal myocardial infarction. In contrast, mortality related to heart failure has remained stable, pointing to the need for improved long-term prevention of congestive heart failure-related mortality as one of the major targets for research in this area. In addition to having more severe coronary disease in the more recent cohorts, patients had a higher burden of noncardiac diseases, and Spoon et al demonstrate, very consistently, a progressive rise in noncardiac deaths over long-term follow-up in recent periods. This is consistent with observations in a recent study of PCI in octogenarians.16 The fact that noncardiovascular causes of death have become dominant after PCI is not entirely surprising. Despite success in reducing the short-term risks associated with PCI, we are operating on older patients who are succumbing to cancer and respiratory, liver, and renal failure in the long run rather than to cardiac causes.17Thus, a new front has opened up in the war against cardiovascular disease, and it has nothing to do with the heart. This observation has several implications. First, from the standpoint of clinical research, although mortality remains the ultimate clinical trial outcome, future clinical trials of cardiovascular outcomes after PCI will need to study outcomes beyond mortality and incorporate nonfatal cardiovascular clinical outcomes and quality of life. Otherwise, trials aiming at mortality reductions would need to be very large. After all, this is to be expected and has been the norm in many other fields in medicine in which mortality reduction is either rare or irrelevant.18 Then there are implications for patient care and even for training of cardiologists. It is a reminder that greater attention should be paid to the patient as a whole, including comorbidities, before committing him or her to an invasive procedure. This observation after PCI is a reflection of a broader trend: The prevalence of comorbidities is increasing in the ever-older cardiology patient population. Whereas in the past many patients would die of cardiac disease prematurely before experiencing the many comorbidities that go along with advanced age, progress in prevention and treatment has now decreased the incidence and lethality of cardiac diseases. In turn, patients surviving long term after an initial heart attack have developed an increased prevalence of comorbidities, the treatment of which may pose more problems to cardiologists than the solution to their cardiologic problem. In many coronary care units, the patient with acute myocardial infarction has now become the "simple" patient compared with the patient in whom a cardiac complaint may be associated with a host of severe comorbidities that often require multiple consultations with specialists. This argues for greater integration of cardiology, as a specialty, with internal medicine, not only in the organization of care but even at the stage of training of junior physicians. It is, in some sense, ironic that the successes of cardiology in tackling cardiac mortality now result in the need to reintegrate cardiology and internal medicine when, for many years, cardiology has sought greater specialization and autonomy.DisclosuresDr Steg reports receiving research grants (to his institution) from Sanofi, Servier, and the New York University School of Medicine and receiving compensation for steering committees, data monitoring committees, consulting, or speaking from Amarin, AstraZeneca, Bayer, Boehringer-Ingelheim, BristolMyersSquibb, Daiichi-Sankyo/Lilly, GlaxoSmithKline, Merck, Novartis, Otsuka, Pfizer, Roche, Sanofi, Servier, The Medicines Company, and Vivus. Dr Steg is a stockholder in Aterovax. Dr Cheong reports no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Philippe Gabriel Steg, MD, Département Hospitalo-Universitaire FIRE, Service de Cardiologie, Hôpital Bichat, 46 Rue Henri Huchard, 75018 Paris, France. E-mail [email protected]References1. Calvert PA, Steg PG. Towards evidence-based percutaneous coronary intervention: the René Laënnec lecture in clinical cardiology.Eur Heart J. 2012; 33:1878–1885.CrossrefMedlineGoogle Scholar2. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.Lancet. 2003; 361:13–20.CrossrefMedlineGoogle Scholar3. Bavry AA, Kumbhani DJ, Rassi AN, Bhatt DL, Askari AT. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials.J Am Coll Cardiol. 2006; 48:1319–1325.CrossrefMedlineGoogle Scholar4. Katritsis DG, Ioannidis JP. Percutaneous coronary intervention versus conservative therapy in nonacute coronary artery disease: a meta-analysis.Circulation. 2005; 111:2906–2912.LinkGoogle Scholar5. Stergiopoulos K, Boden WE, Hartigan P, Möbius-Winkler S, Hambrecht R, Hueb W, Hardison RM, Abbott JD, Brown DL. Percutaneous coronary intervention outcomes in patients with stable obstructive coronary artery disease and myocardial ischemia: a collaborative meta-analysis of contemporary randomized clinical trials [published online ahead or print December 2, 2013].JAMA Intern Med. doi: 10.1001/jamainternmed.2013.12855. http://archinte.jamanetwork.com/article.aspx?articleid=1783047.Google Scholar6. Fassa AA, Wijns W, Kolh P, Steg PG. Benefit of revascularization for stable ischaemic heart disease: the jury is still out.Eur Heart J. 2013; 34:1534–1538.CrossrefMedlineGoogle Scholar7. Spoon DB, Psaltis PJ, Singh M, Holmes DR, Gersh BJ, Rihal CS, Lennon RJ, Moussa ID, Simari RD, Gulati R. Trends in cause of death after percutaneous coronary intervention.Circulation. 2014; 129:1286–1294.LinkGoogle Scholar8. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.BMJ. 2002; 324:71–86.CrossrefMedlineGoogle Scholar9. Al-Mallah MH, Tleyjeh IM, Abdel-Latif AA, Weaver WD. Angiotensin-converting enzyme inhibitors in coronary artery disease and preserved left ventricular systolic function: a systematic review and meta-analysis of randomized controlled trials.J Am Coll Cardiol. 2006; 47:1576–1583.CrossrefMedlineGoogle Scholar10. Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review.JAMA. 2003; 290:86–97.CrossrefMedlineGoogle Scholar11. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.N Engl J Med. 2003; 348:383–393.CrossrefMedlineGoogle Scholar12. Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot J-S, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Taggart DP, van der Wall EE, Vrints CJM, ESC Committee for Practice Guidelines, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Reviewers D, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, Gonzalez-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Kristensen SD, Lancellotti P, Maggioni AP, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Sirnes PA, Steg PG, Timmis A, Wijns W, Windecker S, Yildirir A, Zamorano JL. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the Management of Stable Coronary Artery Disease of the European Society of Cardiology.Eur Heart J. 2013; 34:2949–3003.CrossrefMedlineGoogle Scholar13. Peterson ED, Roe MT, Mulgund J, DeLong ER, Lytle BL, Brindis RG, Smith SC, Pollack CV, Newby LK, Harrington RA, Gibler WB, Ohman EM. Association between hospital process performance and outcomes among patients with acute coronary syndromes.JAMA. 2006; 295:1912–1920.CrossrefMedlineGoogle Scholar14. Newby LK, LaPointe NM, Chen AY, Kramer JM, Hammill BG, DeLong ER, Muhlbaier LH, Califf RM. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease.Circulation. 2006; 113:203–212.LinkGoogle Scholar15. Borden WB, Redberg RF, Mushlin AI, Dai D, Kaltenbach LA, Spertus JA. Patterns and intensity of medical therapy in patients undergoing percutaneous coronary intervention.JAMA. 2011; 305:1882–1889.CrossrefMedlineGoogle Scholar16. Marcolino MS, Simsek C, de Boer SP, van Domburg RT, van Geuns RJ, de Jaegere P, Akkerhuis KM, Daemen J, Serruys PW, Boersma E. Short- and long-term outcomes in octogenarians undergoing percutaneous coronary intervention with stenting.EuroIntervention. 2012; 8:920–928.CrossrefMedlineGoogle Scholar17. Johnman C, Oldroyd KG, Mackay DF, Slack R, Pell AC, Flapan AD, Jennings KP, Eteiba H, Irving J, Pell JP. Percutaneous coronary intervention in the elderly: changes in case-mix and periprocedural outcomes in 31 758 patients treated between 2000 and 2007.Circ Cardiovasc Interv. 2010; 3:341–345.LinkGoogle Scholar18. Bueno H, Armstrong PW, Buxton MJ, Danchin N, Lubsen J, Roland E, Verheugt FW, Zalewski A, Jackson N, Komajda M, Steg PG; Cardiovascular Round Table Clinical Trials ThinkTank Participants. The future of clinical trials in secondary prevention after acute coronary syndromes.Eur Heart J. 2011; 32:1583–1589.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Matsumura K, Kakiuchi Y, Tabuchi T, Takase T, Maruyama M, Ueno M and Nakazawa G (2022) Cancer screening: Possibility of underscreening in older adult population with a history of cardiovascular disease, Journal of Cardiology, 10.1016/j.jjcc.2022.03.002, 80:2, (133-138), Online publication date: 1-Aug-2022. Aboumsallem J, Moslehi J and de Boer R (2020) Reverse Cardio‐Oncology: Cancer Development in Patients With Cardiovascular Disease, Journal of the American Heart Association, 9:2, Online publication date: 21-Jan-2020. Suzuki M, Tomoike H, Sumiyoshi T, Nagatomo Y, Hosoda T, Nagayama M, Ishikawa Y, Sawa T, Iimuro S, Yoshikawa T and Hosoda S (2017) Incidence of cancers in patients with atherosclerotic cardiovascular diseases, IJC Heart & Vasculature, 10.1016/j.ijcha.2017.08.004, 17, (11-16), Online publication date: 1-Dec-2017. Spoon D, Lennon R, Psaltis P, Prasad A, Holmes D, Lerman A, Rihal C, Gersh B, Ting H, Singh M and Gulati R (2015) Prediction of Cardiac and Noncardiac Mortality After Percutaneous Coronary Intervention, Circulation: Cardiovascular Interventions, 8:9, Online publication date: 1-Sep-2015. Elmariah S, Mauri L, Doros G, Galper B, O'Neill K, Steg P, Kereiakes D and Yeh R (2015) Extended duration dual antiplatelet therapy and mortality: a systematic review and meta-analysis, The Lancet, 10.1016/S0140-6736(14)62052-3, 385:9970, (792-798), Online publication date: 1-Feb-2015. March 25, 2014Vol 129, Issue 12 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.114.008492PMID: 24515992 Originally publishedFebruary 10, 2014 Keywordsmortalitymorbiditypercutaneous coronary interventionEditorialsacute coronary syndromePDF download Advertisement SubjectsCoronary Circulation