title: Optimal medical therapy improves clinical outcomes in patients undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting: insights from the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial at the 5-year follow-up.
abstract: BACKGROUND
  There is a paucity of data on the use of optimal medical therapy (OMT) in patients with complex coronary artery disease undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting (CABG) and its long-term prognostic significance.
  
  
  RESULTS
  The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial is a multicenter, randomized, clinical trial of patients (n=1800) with complex coronary disease randomized to revascularization with percutaneous coronary intervention or CABG. Detailed drug history was collected for all patients at discharge and at the 1-month, 6-month, 1-year, 3-year, and 5-year follow-ups. OMT was defined as the combination of at least 1 antiplatelet drug, statin, β-blocker, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Five-year clinical outcomes were stratified by OMT and non-OMT. OMT was underused in patients treated with coronary revascularization, especially CABG. OMT was an independent predictor of survival. OMT was associated with a significant reduction in mortality (hazard ratio, 0.64; 95% confidence interval, 0.48-0.85; P=0.002) and composite end point of death/myocardial infarction/stroke (hazard ratio, 0.73; 95% confidence interval, 0.58-0.92; P=0.007) at the 5-year follow-up. The treatment effect with OMT (36% relative reduction in mortality over 5 years) was greater than the treatment effect of revascularization strategy (26% relative reduction in mortality with CABG versus percutaneous coronary intervention over 5 years). On stratified analysis, all the components of OMT were important for reducing adverse outcomes regardless of revascularization strategy.
  
  
  CONCLUSIONS
  The use of OMT remains low in patients with complex coronary disease requiring coronary intervention with percutaneous coronary intervention and even lower in patients treated with CABG. Lack of OMT is associated with adverse clinical outcomes. Targeted strategies to improve OMT use in postrevascularization patients are warranted.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT00114972.
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Javaid
authors.initials: J
authors.lastname: Iqbal
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Yao-Jun
authors.initials: YJ
authors.lastname: Zhang
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: David R
authors.initials: DR
authors.lastname: Holmes
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Morice
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Mack
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Arie Pieter
authors.initials: AP
authors.lastname: Kappetein
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Ted
authors.initials: T
authors.lastname: Feldman
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Stahle
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Javier
authors.initials: J
authors.lastname: Escaned
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Adrian P
authors.initials: AP
authors.lastname: Banning
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Julian P
authors.initials: JP
authors.lastname: Gunn
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
authors.forename: Friedrich W
authors.initials: FW
authors.lastname: Mohr
authors.affiliation: From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.). p.w.j.c.serruys@erasmusmc.nl.
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
mesh_terms: D000368:Aged; D015415:Biomarkers; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D015897:Comorbidity; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data*; D003327:Coronary Disease / Q000188:drug therapy* / Q000601:surgery; D004363:Drug Utilization; D054855:Drug-Eluting Stents; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D009426:Netherlands / Q000453:epidemiology; D017239:Paclitaxel / Q000008:administration & dosage / Q000627:therapeutic use; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data*; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D002317:Cardiovascular Agents; D017239:Paclitaxel
keywords: coronary artery bypass; coronary artery disease; stents