Geographical differences in the rates of angiographic restenosis and ischemia-driven target vessel revascularization after percutaneous coronary interventions: results from the Prevention of Restenosis With Tranilast and its Outcomes (PRESTO) Trial.
Many cardiologists consider it reasonable to assume in clinical practice that percutaneous coronary intervention using drug-eluting stents ought to be considered equivalent, if not superior, to bypass surgery. In the absence of a definitive clinical trial to support this view, how should the prudent, cutting-edge cardiologist proceed?


OBJECTIVE
This study assessed the geographical differences in target vessel revascularization (TVR) after percutaneous coronary intervention (PCI) in the Prevention of Restenosis With Tranilast and its Outcomes (PRESTO) trial.


BACKGROUND
An aggressive approach to PCI is more common in the U.S. than in other countries. The impact of this approach on restenosis outcomes has not been studied.


METHODS
Using the PRESTO trial, we compared nine-month ischemic TVR after PCI in U.S.-treated patients (n = 5,026) with rates in other countries (n = 6,458). We defined TVR as repeat intervention for chest pain/positive stress test. Additionally, angiographic restenosis (> or =50% narrowing or > or =50% loss of gain at nine-month follow-up) was compared between U.S. and non-U.S. patients within the prespecified angiographic subset (n = 2,823). Regression models were developed to adjust for clinical and lesion-related characteristics.


RESULTS
Higher rates of TVR (18% vs. 11%), and angiographic restenosis (65% vs. 48%) were observed in patients treated in the U.S. as compared with the other patients (p < 0.01 for both comparisons). Patients treated in the U.S. were more likely to be female, diabetic, not currently smoking, to have unstable angina, and to have a prior PCI. In U.S. patients, lesions tended to be longer, but less likely to be American College of Cardiology/American Heart Association class C. After adjusting for clinical and angiographic variables, PCI in the U.S. was still associated with increased angiographic restenosis and ischemic TVR.


CONCLUSIONS
Angiographic restenosis and ischemia-driven TVR rates were higher in patients treated in the U.S. The difference could only partially be explained by the higher prevalence of measured adverse clinical and angiographic features.
Singh
Mandeep
M
Division of Internal Medicine and Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.
Williams
Brent A
BA
Gersh
Bernard J
BJ
McClelland
Robyn L
RL
Ho
Kalon K L
KK
Willerson
James T
JT
Penny
William F
WF
Cutlip
Donald E
DE
Holmes
David R
DR
D015906:Angioplasty, Balloon, Coronary; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use*; D001315:Australia; D002170:Canada; D017023:Coronary Angiography; D023903:Coronary Restenosis / Q000000981:diagnostic imaging / Q000517:prevention & control / Q000628:therapy*; D005060:Europe; D006801:Humans; D015337:Multicenter Studies as Topic; D016032:Randomized Controlled Trials as Topic; D019233:Retreatment; D013019:South Africa; D016896:Treatment Outcome; D014481:United States; D062367:ortho-Aminobenzoates / Q000627:therapeutic use*
D000894:Anti-Inflammatory Agents, Non-Steroidal; D062367:ortho-Aminobenzoates; C012293:tranilast