title: Impact of the presence and extent of incomplete angiographic revascularization after percutaneous coronary intervention in acute coronary syndromes: the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial.
abstract: BACKGROUND
  The clinical significance of incomplete coronary revascularization (ICR) after percutaneous coronary intervention in patients with acute coronary syndromes is unknown.
  
  
  RESULTS
  We performed quantitative angiography of the entire coronary tree in 2954 patients with acute coronary syndromes in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. ICR was variably defined if any lesion with diameter stenosis (DS) cutoffs ranging from ≥30% to ≥70% with reference vessel diameter ≥2.0 mm remained after percutaneous coronary intervention. The primary outcome was 1-year composite rate of major adverse cardiac events (death, myocardial infarction, or ischemia-driven unplanned revascularization). With the use of DS cutoffs ≥30%, ≥40%, ≥50%, ≥60%, and ≥70%, the prevalence of ICR after percutaneous coronary intervention was 75%, 55%, 37%, 25%, and 17%, respectively. The 1-year major adverse cardiac event rate was increased among patients with ICR using all of the DS cutoffs. ICR (≥50% DS) was associated with higher 1-year rates of myocardial infarction (12.0% versus 8.2%; hazard ratio, 1.50; 95% confidence interval, 1.18-1.89; P=0.0007) and ischemia-driven unplanned revascularization (15.7% versus 10.2%; hazard ratio, 1.58; 95% confidence interval, 1.28-1.96; P<0.0001), with a trend toward increased mortality (3.1% versus 2.2%; hazard ratio, 1.43; 95% confidence interval, 0.90-2.27; P=0.13). By multivariable analysis, ICR (≥50% DS) was an independent predictor of 1-year major adverse cardiac events (hazard ratio, 1.36; 95% confidence interval, 1.12-1.64; P=0.002). The impact of ICR on major adverse cardiac events was similar regardless of chronic total occlusion presence, but it was more pronounced with a greater number of nonrevascularized lesions.
  
  
  CONCLUSIONS
  Depending on the threshold of percent DS, ICR was present in 17% to 75% of patients with acute coronary syndromes after percutaneous coronary intervention. Regardless of the threshold, ICR was strongly associated with 1-year myocardial infarction, ischemia-driven unplanned revascularization, and major adverse cardiac events.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.
authors.affiliation: New York-Presbyterian Hospital, Columbia University Medical Center, Cardiovascular Research Foundation, NY 10022, USA.
authors.forename: Gregg F
authors.initials: GF
authors.lastname: Rosner
authors.forename: Ajay J
authors.initials: AJ
authors.lastname: Kirtane
authors.forename: Philippe
authors.initials: P
authors.lastname: Genereux
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Lansky
authors.forename: Ecaterina
authors.initials: E
authors.lastname: Cristea
authors.forename: Bernard J
authors.initials: BJ
authors.lastname: Gersh
authors.forename: Giora
authors.initials: G
authors.lastname: Weisz
authors.forename: Helen
authors.initials: H
authors.lastname: Parise
authors.forename: Martin
authors.initials: M
authors.lastname: Fahy
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging* / Q000628:therapy*; D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000453:epidemiology*; D009204:Myocardial Revascularization / Q000009:adverse effects*; D017063:Outcome Assessment, Health Care; D015995:Prevalence; D011446:Prospective Studies; D012307:Risk Factors