title: Comparison of stenting and surgical revascularization strategy in non-ST elevation acute coronary syndromes and complex coronary artery disease (from the Milestone Registry).
abstract: The optimal revascularization strategy in patients with complex coronary artery disease and non-ST-segment elevation acute coronary syndromes is undetermined. In this multicenter, prospective registry, 4,566 patients with non-ST-segment elevation myocardial infarctions, unstable angina, and multivessel coronary disease, including left main disease, were enrolled. After angiography, 3,033 patients were selected for stenting (10.3% received drug-eluting stents) and 1,533 for coronary artery bypass grafting. Propensity scores were used for baseline characteristic matching and result adjustment. Patients selected for percutaneous coronary intervention (PCI) were younger (mean age 64.4±10 vs 65.2±9 years, p=0.03) and more frequently presented with non-ST-segment elevation myocardial infarctions (32.0% vs 14.5%, p=0.01), cardiogenic shock (1.5% vs 0.7%, p<0.01), and history of PCI (13.1% vs 5.5%, p<0.01) or coronary artery bypass grafting (10.6% vs 4.6%, p<0.01). European System for Cardiac Operative Risk Evaluation scores were higher in PCI patients (5.4±2 vs 5.2±2, p<0.01). Patients referred for coronary artery bypass grafting more often presented with triple-vessel disease and left main disease (82.2% vs 33.8% and 13.7% vs 2.4%, respectively, p<0.01). After adjustment, 929 well-matched pairs were chosen. Early mortality was lower after PCI before matching (2.1% vs 3.1%, p<0.01), whereas after balancing, there was no difference (2.5% vs 2.8%, p=0.62). Three-year survival was in favor of PCI compared with surgery before (87.5% vs 82.8%, hazard ratio 1.44, 95% confidence interval 1.2 to 1.7, p<0.01) and after (86.4% vs 82.3%, hazard ratio 1.33, 95% confidence interval 1.05 to 1.7, p=0.01). Stenting was associated with improved outcomes in the following subgroups: patients aged >65 years, women, patients with unstable angina, those with European System for Cardiac Operative Risk Evaluation scores>5, those with Thrombolysis In Myocardial Infarction (TIMI) risk scores >4, those receiving drug-eluting stents, and those with 2-vessel disease. In conclusion, in patients presenting with non-ST-segment elevation acute coronary syndromes and complex coronary artery disease, immediate stenting was associated with lower mortality risk in the long term compared with surgical revascularization, especially in subgroups at high clinical risk.
authors.affiliation: American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland.
authors.forename: Pawel E
authors.initials: PE
authors.lastname: Buszman
authors.affiliation: American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland; III Clinical Department of Cardiology, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland. Electronic address: p.buszman@ahp-ccrd.org.
authors.forename: Piotr P
authors.initials: PP
authors.lastname: Buszman
authors.affiliation: American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland.
authors.forename: Andrzej
authors.initials: A
authors.lastname: Bochenek
authors.affiliation: III Clinical Department of Cardiology, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland.
authors.forename: Marek
authors.initials: M
authors.lastname: Gierlotka
authors.affiliation: III Clinical Department of Cardiology, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland.
authors.forename: Mariusz
authors.initials: M
authors.lastname: Gąsior
authors.affiliation: American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland.
authors.forename: Krzysztof
authors.initials: K
authors.lastname: Milewski
authors.affiliation: American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland.
authors.forename: Bartłomiej
authors.initials: B
authors.lastname: Orlik
authors.affiliation: American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland.
authors.forename: Adam
authors.initials: A
authors.lastname: Janas
authors.affiliation: American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland; IIIrd Clinical Division of Cardiology, Medical University of Silesia in Katowice, Katowice, Poland.
authors.forename: Wojciech
authors.initials: W
authors.lastname: Wojakowski
authors.affiliation: American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland; University of Texas Health Sciences, San Antonio, Texas.
authors.forename: R Stefan
authors.initials: RS
authors.lastname: Kiesz
authors.affiliation: Department of Cardiac Surgery and Transplantology, Silesian Center for Heart Diseases, Zabrze, Poland.
authors.forename: Marian
authors.initials: M
authors.lastname: Zembala
authors.affiliation: III Clinical Department of Cardiology, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiac Surgery and Transplantology, Silesian Center for Heart Diseases, Zabrze, Poland.
authors.forename: Lech
authors.initials: L
authors.lastname: Poloński
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D000368:Aged; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000379:methods*; D011044:Poland / Q000453:epidemiology; D011446:Prospective Studies; D015607:Stents; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome