title: Five-year follow-up of patients treated for coronary artery disease in the face of an increasing burden of co-morbidity and disease complexity (from the NHLBI Dynamic Registry).
abstract: Management of coronary artery disease (CAD) has evolved over the past decade, but there are few prospective studies evaluating long-term outcomes in a real-world setting of evolving technical approaches and secondary prevention. The aim of this study was to determine how the mortality and morbidity of CAD has changed in patients who have undergone percutaneous coronary intervention (PCI), in the setting of co-morbidities and evolving management. The National Heart, Lung, and Blood Institute Dynamic Registry was a cohort study of patients undergoing PCI at various time points. Cohorts were enrolled in 1999 (cohort 2, n = 2,105), 2004 (cohort 4, n = 2,112), and 2006 (cohort 5, n = 2,176), and each was followed out to 5 years. Primary outcomes were death, myocardial infarction (MI), coronary artery bypass grafting, repeat PCI, and repeat revascularization. Secondary outcomes were PCI for new obstructive lesions at 5 years, 5-year rates of death and MI stratified by the severity of coronary artery and co-morbid disease. Over time, patients were more likely to have multiple co-morbidities and more severe CAD. Despite greater disease severity, there was no significant difference in death (16.5% vs 17.6%, adjusted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.74 to 1.08), MI (11.0% vs 10.6%, adjusted HR 0.87, 95% CI 0.70 to 1.08), or repeat PCI (20.4% vs 22.2%, adjusted HR 0.98, 95% CI 0.85 to 1.17) at 5-year follow-up, but there was a significant decrease in coronary artery bypass grafting (9.1% vs 4.3%, adjusted HR 0.44, 95% CI 0.32 to 0.59). Patients with 5 co-morbidities had a 40% to 60% death rate at 5 years. There was a modestly high rate of repeat PCI for new lesions, indicating a potential failure of secondary prevention for this population in the face of increasing co-morbidity. Overall 5-year rates of death, MI, repeat PCI, and repeat PCI for new lesions did not change significantly in the context of increased co-morbidities and complex disease.
authors.affiliation: Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Anna E
authors.initials: AE
authors.lastname: Bortnick
authors.affiliation: Division of Cardiovascular Medicine, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Kelly C
authors.initials: KC
authors.lastname: Epps
authors.affiliation: Department of Epidemiology, The University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Faith
authors.initials: F
authors.lastname: Selzer
authors.affiliation: Division of Cardiovascular Medicine, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Saif
authors.initials: S
authors.lastname: Anwaruddin
authors.affiliation: Department of Epidemiology, The University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania.
authors.forename: Oscar C
authors.initials: OC
authors.lastname: Marroquin
authors.affiliation: Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Vankeepuram
authors.initials: V
authors.lastname: Srinivas
authors.affiliation: Division of Cardiology, Medical City Hospital, Dallas, Texas.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Holper
authors.affiliation: Division of Cardiovascular Medicine, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: robert.wilensky@uphs.upenn.edu.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Wilensky
mesh_terms: D000368:Aged; D015331:Cohort Studies; D015897:Comorbidity; D003324:Coronary Artery Disease / Q000401:mortality* / Q000601:surgery*; D003331:Coronary Vessels / Q000473:pathology* / Q000601:surgery; D017281:Cost of Illness; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D054555:National Heart, Lung, and Blood Institute (U.S.); D062645:Percutaneous Coronary Intervention / Q000401:mortality*; D012042:Registries; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology