Long-term outcomes in surgically ineligible patients managed with percutaneous coronary revascularization or medical therapy

  • Edward James Frazer DansonEmail author
  • James Sapontis
  • Amit Kaura
  • Jonathan Michael Hill
  • Rafal Dworakowski
  • Philip MacCarthy
  • Narbeh Melikian
  • Ian Webb
  • Ajay Shah
  • Jonathan Byrne
Original Article


The objective of the study was to report clinical outcomes of patients unsuitable for surgical coronary revascularization (CABG) treated with percutaneous revascularization (PCI) or medical therapy alone (MT). The decision to revascularize patients referred for CABG but who are unsuitable should be made at Heart Team meetings. The clinical outcomes in this important patient subset are not known, and while cases are considered individually, these decisions are not guided by robust data. Clinical data were analyzed for patients referred to the Heart Team for consideration of CABG over a 4-year period in a UK tertiary referral center. Outcome data for those managed with urgent PCI or MT were considered over a further 3-year period. 133 patients were treated with PCI and 117 with MT. MACE at 30 days were no different between groups (MT 10.3% versus PCI 12.2%); however, at 1 year MACE were higher in the MT group (MT 39.3% versus PCI 26.7%, P < 0.01). Log rank for MACE-free survival to 1 and 3 years was significantly lower in the MT group [HR 1.77 (0.60–1.11); P < 0.001]. Residual SYNTAX was an independent predictor of death. MT [OR 1.75 (1.03–2.99); P = 0.04] and a residual SYNTAX score [OR 6.45 (2.53–16.45); P < 0.001] were independent predictors of MACE at 1 year in the whole group. Our data reveal better outcomes in patients treated with PCI over MT at 1–3 years in CABG-ineligible patients. Patients without complete revascularization have worse outcomes.


PCI Risk stratification Drug-eluting stent 


Compliance with ethical standards

Conflict of interest

No conflict of interest to disclose.


  1. 1.
    Head SJ, Holmes DR Jr, Mack MJ, Serruys PW, Mohr FW, Morice MC, Colombo A, Kappetein AP, SYNTAX Investigators. Risk profile and 3 year outcomes from the SYNTAX percutaneous coronary intervention and coronary artery bypass grafting nested registries. JACC Cardiovasc Interv. 2012;5:618–25.CrossRefGoogle Scholar
  2. 2.
    McNulty EJ, Ng W, Spertus JA, Zaroff JG, Yeh RW, Ren XM, Lundstrom RJ. Surgical candidacy and selection biases in non-emergent left main stenting: implications for observational studies. JACC Cardiovasc Interv. 2011;4:1020–7.CrossRefGoogle Scholar
  3. 3.
    Windecker S, Stortecky S, Stefanini GG, da Costa BR, Rutjes AW, Di Nisio M, Silletta MG, Maione A, Alfonso F, Clemmensen PM, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head S, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter D, Schauerte P, Sousa Uva M, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A, Kolh P, Jüni P. Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis. BMJ. 2014;348:g3859.CrossRefGoogle Scholar
  4. 4.
    Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, Ståhle E, Feldman TE, van den Brand M, Bass EJ, Van Dyck N, Leadley K, Dawkins KD, Mohr FW, SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360:961–72.CrossRefGoogle Scholar
  5. 5.
    Califf RM, Phillips HR 3rd, Hindman MC, Mark DB, Lee KL, Behar VS, Johnson RA, Pryor DB, Rosati RA, Wagner GS. Prognostic value of a coronary artery jeopardy score. J Am Coll Cardiol. 1985;5:1055–63.CrossRefGoogle Scholar
  6. 6.
    Girasis C, Garg S, Räber L, Sarno G, Morel MA, Garcia-Garcia HM, Lüscher TF, Serruys PW, Windecker S. SYNTAX score and Clinical SYNTAX score as predictors of very long-term clinical outcomes in patients undergoing percutaneous coronary interventions: a substudy of SIRolimus-eluting stent compared with pacliTAXel-eluting stent for coronary revascularization (SIRTAX) trial. Eur Heart J. 2011;32:3115–27.CrossRefGoogle Scholar
  7. 7.
    Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A, Mack MJ, Holmes DR Jr, Morel MA, Van Dyck N, Houle VM, Dawkins KD, Serruys PW. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013;381:629–38.CrossRefGoogle Scholar
  8. 8.
    Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A, Mack MJ, Holmes DR, Choi JW, Ruzyllo W, Religa G, Huang J, Roy K, Dawkins KD, Mohr F. Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with taxus and cardiac surgery trial. Circulation. 2014;129:2388–94.CrossRefGoogle Scholar
  9. 9.
    Park SJ, Kim YH, Park DW, Yun SC, Ahn JM, Song HG, Lee JY, Kim WJ, Kang SJ, Lee SW, Lee CW, Park SW, Chung CH, Lee JW, Lim DS, Rha SW, Lee SG, Gwon HC, Kim HS, Chae IH, Jang Y, Jeong MH, Tahk SJ, Seung KB. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011;364:1718–27.CrossRefGoogle Scholar
  10. 10.
    Stone GW, Sabik JF, Serruys PW, Simonton CA, Généreux P, Puskas J, Kandzari DE, Morice MC, Lembo N, Brown WM 3rd, Taggart DP, Banning A, Merkely B, Horkay F, Boonstra PW, van Boven AJ, Ungi I, Bogáts G, Mansour S, Noiseux N, Sabaté M, Pomar J, Hickey M, Gershlick A, Buszman P, Bochenek A, Schampaert E, Pagé P, Dressler O, Kosmidou I, Mehran R, Pocock SJ, Kappetein AP, EXCEL Trial Investigators. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med. 2016;375:2223–35.CrossRefGoogle Scholar
  11. 11.
    Mäkikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IB, Trovik T, Eskola M, Romppanen H, Kellerth T, Ravkilde J, Jensen LO, Kalinauskas G, Linder RB, Pentikainen M, Hervold A, Banning A, Zaman A, Cotton J, Eriksen E, Margus S, Sørensen HT, Nielsen PH, Niemelä M, Kervinen K, Lassen JF, Maeng M, Oldroyd K, Berg G, Walsh SJ, Hanratty CG, Kumsars I, Stradins P, Steigen TK, Fröbert O, Graham AN, Endresen PC, Corbascio M, Kajander O, Trivedi U, Hartikainen J, Anttila V, Hildick-Smith D, Thuesen L, Christiansen EH, NOBLE study investigators. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016;388:2743–52.CrossRefGoogle Scholar
  12. 12.
    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 JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Taggart DP, van der Wall EE, Vrints CJ, 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, 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, Task Force Members, ESC Committee for Practice Guidelines, Document Reviewers. 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.CrossRefGoogle Scholar
  13. 13.
    Morrison DA, Sethi G, Sacks J, Henderson W, Grover F, Sedlis S, Esposito R, Ramanathan K, Weiman D, Saucedo J, Antakli T, Paramesh V, Pett S, Vernon S, Birjiniuk V, Welt F, Krucoff M, Wolfe W, Lucke JC, Mediratta S, Booth D, Barbiere C, Lewis D, Investigators of the Department of Veterans Affairs Cooperative Study #385, the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME). Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial. J Am Coll Cardiol. 2001;38:143–9.CrossRefGoogle Scholar
  14. 14.
    Morrison DA, Sethi G, Sacks J, Henderson WG, Grover F, Sedlis S, Esposito R. Percutaneous coronary intervention versus repeat bypass surgery for patients with medically refractory myocardial ischemia: AWESOME randomized trial and registry experience with post-CABG patients. J Am Coll Cardiol. 2002;40:1951–4.CrossRefGoogle Scholar
  15. 15.
    Hordijk-Trion M, Lenzen M, Wijns W, de Jaegere P, Simoons ML, Scholte op Reimer WJ, Bertrand ME, Mercado N, Mercado N, Boersma E, EHS-CR Investigators. Patients enrolled in coronary intervention trials are not representative of patients in clinical practice: results from the Euro Heart Survey on Coronary Revascularization. Eur Heart J. 2006;27:671–8.CrossRefGoogle Scholar
  16. 16.
    Sambola A, Mutuberría M, García Del Blanco B, Alonso A, Barrabés JA, Bueno H, Alfonso F, Cequier A, Zueco J, Rodríguez-Leor O, Tornos P, García-Dorado D. Impact of triple therapy in elderly patients with atrial fibrillation undergoing percutaneous coronary intervention. PLoS ONE. 2016;11:e0147245.CrossRefGoogle Scholar
  17. 17.
    Gale CP, Allan V, Cattle BA, Hall AS, West RM, Timmis A, Gray HH, Deanfield J, Fox KA, Feltbower R. Trends in hospital treatments, including revascularisation, following acute myocardial infarction, 2003–2010: a multilevel and relative survival analysis for the National Institute for Cardiovascular Outcomes Research (NICOR). Heart. 2014;100:582–9.CrossRefGoogle Scholar
  18. 18.
    Gyenes GT, Yan AT, Tan M, Welsh RC, Fox KA, Grondin FR, Deyoung JP, Rose BF, Gallo R, Kornder JM, Wong GC, Goodman SG, Canadian Global Registry of Acute Coronary Events (GRACE/GRACE(2)), Canadian Registry of Acute Coronary Events (CANRACE) Investigators. Use and timing of coronary angiography and associated in-hospital outcomes in Canadian non-ST-segment elevation myocardial infarction patients: insights from the Canadian Global Registry of Acute Coronary Events. Can J Cardiol. 2013;29:1429–35.CrossRefGoogle Scholar
  19. 19.
    Hall M, Laut K, Dondo TB, Alabas OA, Brogan RA, Gutacker N, Cookson R, Norman P, Timmis A, de Belder M, Ludman PF, Gale CP. Patient and hospital determinants of primary percutaneous coronary intervention in England, 2003–2013. Heart. 2016. Scholar
  20. 20.
    Atreya AR, Sivalingam SK, Arora S, Kashef MA, Fitzgerald J, Visintainer P, Lotfi A, Rothberg MB. Predictors of medical management in patients undergoing elective cardiac catheterization for chronic ischemic heart disease. Clin Cardiol. 2016. Scholar
  21. 21.
    Shuvy M, Guo H, Wijeysundera HC, Feindel CM, Cohen EA, Austin PC, Kingsbury K, Natarajan MK, Tu JV, Ko DT. Medical therapy and coronary revascularization for patients with stable coronary artery disease and unclassified appropriateness score. Am J Cardiol. 2015;116:1815–21.CrossRefGoogle Scholar
  22. 22.
    Gada H, Kirtane AJ, Kereiakes DJ, Bangalore S, Moses JW, Généreux P, Mehran R, Dangas GD, Leon MB, Stone GW. Meta-analysis of trials on mortality after percutaneous coronary intervention compared with medical therapy in patients with stable coronary heart disease and objective evidence of myocardial ischemia. Am J Cardiol. 2015;115:1194–9.CrossRefGoogle Scholar
  23. 23.
    Cavender MA, Alexander KP, Broderick S, Shaw LK, McCants CB, Kempf J, Ohman EM. Long-term morbidity and mortality among medically managed patients with angina and multivessel coronary artery disease. Am Heart J. 2009;158:933–40.CrossRefGoogle Scholar
  24. 24.
    Bettinger N, Palmerini T, Caixeta A, Dressler O, Litherland C, Francese DP, Giustino G, Mehran R, Leon MB, Stone GW, Généreux P. Risk stratification of patients undergoing medical therapy after coronary angiography. Eur Heart J. 2016;37(40):3103–10.CrossRefGoogle Scholar
  25. 25.
    Cavender MA, Milford-Beland S, Roe MT, Peterson ED, Weintraub WS, Rao SV. Prevalence, predictors, and in-hospital outcomes of non-infarct artery intervention during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (from the National Cardiovascular Data Registry). Am J Cardiol. 2009;104:507–13.CrossRefGoogle Scholar
  26. 26.
    Jensen LO, Thayssen P, Farkas DK, Hougaard M, Terkelsen CJ, Tilsted HH, Maeng M, Junker A, Lassen JF, Horváth-Puhó E, Sørensen HT, Thuesen L. Culprit only or multivessel percutaneous coronary interventions in patients with ST-segment elevation myocardial infarction and multivessel disease. EuroIntervention. 2012;8:456–64.CrossRefGoogle Scholar
  27. 27.
    Hambraeus K, Jensevik K, Lagerqvist B, Lindahl B, Carlsson R, Farzaneh-Far R, Kellerth T, Omerovic E, Stone G, Varenhorst C, James S. Long-term outcome of incomplete revascularization after percutaneous coronary intervention in SCAAR (Swedish Coronary Angiography and Angioplasty Registry). JACC Cardiovasc Interv. 2016;9:207–15.CrossRefGoogle Scholar
  28. 28.
    Kelbæk H, Høfsten DE, Køber L, Helqvist S, Kløvgaard L, Holmvang L, Jørgensen E, Pedersen F, Saunamäki K, De Backer O, Bang LE, Kofoed KF, Lønborg J, Ahtarovski K, Vejlstrup N, Bøtker HE, Terkelsen CJ, Christiansen EH, Ravkilde J, Tilsted HH, Villadsen AB, Aarøe J, Jensen SE, Raungaard B, Jensen LO, Clemmensen P, Grande P, Madsen JK, Torp-Pedersen C, Engstrøm T. Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial. Lancet. 2016. Scholar

Copyright information

© Japanese Association of Cardiovascular Intervention and Therapeutics 2018

Authors and Affiliations

  • Edward James Frazer Danson
    • 1
    • 3
    Email author
  • James Sapontis
    • 2
  • Amit Kaura
    • 1
  • Jonathan Michael Hill
    • 1
  • Rafal Dworakowski
    • 1
  • Philip MacCarthy
    • 1
  • Narbeh Melikian
    • 1
  • Ian Webb
    • 1
  • Ajay Shah
    • 1
  • Jonathan Byrne
    • 1
  1. 1.King’s College HospitalLondonUK
  2. 2.Monash Medical CentreMelbourneAustralia
  3. 3.University of WollongongWollongongAustralia

Personalised recommendations