title: Prognostic value of angiographic lesion complexity in patients with acute coronary syndromes undergoing percutaneous coronary intervention (from the acute catheterization and urgent intervention triage strategy trial).
abstract: Although lesion complexity is predictive of outcomes after balloon angioplasty, it is unclear whether complex lesions continue to portend a worse prognosis in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) with contemporary interventional therapies. We sought to assess the impact of angiographic lesion complexity, defined by the modified American College of Cardiology/American Heart Association classification, on clinical outcomes after PCI in patients with ACS and to determine whether an interaction exists between lesion complexity and antithrombin regimen outcomes after PCI. Among the 3,661 patients who underwent PCI in the Acute Catheterization and Urgent Intervention Triage strategy study, patients with type C lesions (n = 1,654 [45%]) had higher 30-day rates of mortality (1.2% vs 0.6%, p = 0.049), myocardial infarction (9.2% vs 6.3%, p = 0.0006), and unplanned revascularization (4.3% vs 3.1%, p = 0.04) compared with those without type C lesions. In multivariate analysis, type C lesions were independently associated with myocardial infarction (odds ratio [95% confidence interval] = 1.37 [1.04 to 1.80], p = 0.02) and composite ischemia (odds ratio [95% confidence interval] = 1.49 [1.17 to 1.88], p = 0.001) at 30 days. Bivalirudin monotherapy compared with heparin plus a glycoprotein IIb/IIIa inhibitor reduced major bleeding complications with similar rates of composite ischemic events, regardless of the presence of type C lesions. There were no interactions between antithrombotic regimens and lesion complexity in terms of composite ischemia and major bleeding (p [interaction] = 0.91 and 0.80, respectively). In conclusion, patients with ACS with type C lesion characteristics undergoing PCI have an adverse short-term prognosis. Treatment with bivalirudin monotherapy reduces major hemorrhagic complications irrespective of lesion complexity with comparable suppression of adverse ischemic events as heparin plus glycoprotein IIb/IIIa inhibitor.
authors.affiliation: Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Kenji
authors.initials: K
authors.lastname: Goto
authors.affiliation: Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut. Electronic address: alexandra.lansky@yale.edu.
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Lansky
authors.affiliation: Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Vivian G
authors.initials: VG
authors.lastname: Ng
authors.affiliation: Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Cody
authors.initials: C
authors.lastname: Pietras
authors.affiliation: Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Erol
authors.initials: E
authors.lastname: Nargileci
authors.affiliation: Division of Cardiology, Columbia University Medical Center, New York, New York; Division of Cardiology, Cardiovascular Research Foundation, New York, New York.
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.affiliation: Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Helen
authors.initials: H
authors.lastname: Parise
authors.affiliation: Division of Cardiology, New York University School of Medicine, New York, New York.
authors.forename: Frederick
authors.initials: F
authors.lastname: Feit
authors.affiliation: Department of Medicine - Cardiology, Duke University School of Medicine, Durham, North Carolina.
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.affiliation: Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.affiliation: Hôpital Cardiologique, Lille, France.
authors.forename: Michel E
authors.initials: ME
authors.lastname: Bertrand
authors.affiliation: Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium.
authors.forename: Walter
authors.initials: W
authors.lastname: Desmet
authors.affiliation: Department of Cardiology, University of Caen, Normandy, France.
authors.forename: Martial
authors.initials: M
authors.lastname: Hamon
authors.affiliation: Division of Cardiology, Columbia University Medical Center, New York, New York; Division of Cardiology, Cardiovascular Research Foundation, New York, New York.
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D054058:Acute Coronary Syndrome / Q000401:mortality / Q000628:therapy*; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced; D006493:Heparin / Q000627:therapeutic use; D006629:Hirudins; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000401:mortality / Q000517:prevention & control*; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D016017:Odds Ratio; D010446:Peptide Fragments / Q000627:therapeutic use*; D062645:Percutaneous Coronary Intervention; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D011379:Prognosis; D011994:Recombinant Proteins / Q000627:therapeutic use; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D006629:Hirudins; D010446:Peptide Fragments; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011994:Recombinant Proteins; D006493:Heparin; C074619:bivalirudin