Impact of the Presence and Extent of Incomplete Angiographic Revascularization After Percutaneous Coronary Intervention in Acute Coronary Syndromes: The ACUITY Trial
Background—The clinical significance of incomplete coronary revascularization (ICR) following percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) is unknown.
Methods and Results—We performed quantitative angiography of the entire coronary tree in 2,954 patients with ACS in the 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 following PCI. The primary outcome was 1-year composite rate of major adverse cardiac events (MACE: death, myocardial infarction (MI), or ischemia-driven unplanned revascularization). Using DS cutoffs ≥30%, ≥40%, ≥50%, ≥60% and ≥70%, the prevalence of ICR after PCI was 75%, 55%, 37%, 25%, and 17% respectively. One-year MACE was increased among patients with ICR using all of the DS cutoffs. ICR (≥50% DS) was associated with higher 1-year rates of MI (12.0% vs. 8.2%, HR[95%CI] = 1.50 [1.18,1.89], p=0.0007) and ischemia-driven unplanned revascularization (15.7% vs. 10.2%, HR[95%CI] = 1.58 [1.28,1.96], p<0.0001), with a trend toward increased mortality (3.1% vs. 2.2%, HR[95%CI] = 1.43 [0.90,2.27], p=0.13). By multivariable analysis, ICR (≥50% DS) was an independent predictor of 1-year MACE (HR [95%CI] = 1.36 [1.12,1.64], p=0.002). The impact of ICR on MACE was similar regardless of chronic total occlusion presence, but was more pronounced with a greater number of non-revascularized lesions.
Conclusions—Depending on the threshold %DS, ICR was present in 17%-75% of patients with ACS after PCI. Regardless of the threshold, ICR was strongly associated with 1-year MI, ischemia-driven unplanned revascularization and MACE.
Clinical Trial Registration Information—clinicaltrials.gov; Identifier: NCT00093158
- acute coronary syndrome
- percutaneous coronary intervention
- complete coronary revascularization
- incomplete coronary revascularization
- Received September 21, 2011.
- Accepted March 19, 2012.
- Copyright © 2012, American Heart Association, Inc. All rights reserved. Unauthorized use prohibited