Optimal Medical Therapy Improves Clinical Outcomes in Patients Undergoing Revascularization with Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting: Insights From the SYNTAX Trial at 5-Year Follow-Up
Background—There is a paucity of data on usage of optimal medical therapy (OMT) in patients with complex coronary artery disease undergoing revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) and its long-term prognostic significance.
Methods and Results—SYNTAX is a multicenter randomized clinical trial of patients (n=1800) with complex coronary disease randomized to revascularization with PCI or CABG. Detailed drug history was collected for all the patients at discharge, 1-month, 6-month, 1-year, 3-year and 5-year follow-up. OMT was defined as the combination of at least one antiplatelet drug, statin, beta-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 (HR 0.64, 95% CI 0.48-0.85, p=0.002) and composite endpoint of death/MI/stroke (HR 0.73, 95% CI 0.58-0.92, p=0.007) at 5-year follow-up. The treatment effect with OMT (36% relative reduction in mortality over 5-year) was greater than the treatment effect of revascularization strategy (26% relative reduction in mortality with CABG versus PCI over 5-year). On stratified analysis, all the components of OMT were important for reducing adverse outcomes irrespective of revascularization strategy.
Conclusions—Use of OMT remains low in patients with complex coronary disease requiring coronary intervention with PCI and even more with CABG. Lack of OMT is associated with adverse clinical outcomes. Targeted strategies to improve OMT usage in post revascularization patients are warranted.
Clinical Trial Registration Information—www.clinicaltrials.gov. Identifier: NCT00114972.
- Received August 31, 2014.
- Revision received January 19, 2015.
- Accepted January 26, 2015.