Individual randomized studies have shown variable results regarding the mortality risk following treatment of left main coronary artery disease (LMCAD), either through percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). However, upon assessment of the latest meta-analyses (with matched data), similar risks of all-cause and cardiovascular mortality have been reported for both groups. It is worth noting that few data have been provided on rehospitalization rates following treatment of LMCAD, whether with PCI or CABG.
The aim of this work, presented by Kosmidou et al., was to determine the incidence, predictors, and impact on mortality when evaluating readmission for cardiovascular (CV) and non-cardiovascular (non-CV) causes in patients with left main disease from the EXCEL study.
As a reminder, the EXCEL study was an international multicenter, randomized study comparing everolimus-eluting stents against CABG in patients with LMCAD with low to intermediate SYNTAX scores (≤32). These patients were eligible candidates for revascularization with both techniques. In this follow-up, readmissions were classified as CV or non-CV.
The mean follow-up was 5.02 years (Q1-Q3: 4.95-5.09 years). During that period, there were 1868 readmissions in 851 out of 1882 (45.2%) patients who were discharged alive after the index procedure. Approximately half of these readmissions were due to CV causes, and the other half was due to non-CV factors (927 [49.6%] and 941 [50.4%], respectively). Patients with one or more readmissions were generally older with a higher burden of comorbidities (including diabetes, heart failure, kidney disease, anemia, chronic obstructive pulmonary disease, and peripheral vascular disease), higher incidence of previous myocardial infarction, and lower ejection fraction. Most of them were women.
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As observed, patients who underwent PCI had one or more readmissions for any cause in 48.6% of cases, compared with 41.8% of patients undergoing CABG (P=0.003). When performing an annualized event rate, the PCI group had a rate of 31.2% per patient-year compared with 25% per patient-year for CABG (hazard ratio [HR]: 1.33; 95% confidence interval [CI]: 1.12-1.56; P ≤0.0008). Of all readmissions, 9.8% occurred within 30 days, with a similar rate between the two strategies (87 [4.6%] vs 96 [5.1%], respectively; P = 0.39).
Cardiac and bleeding-related readmissions were more frequent in the PCI group, while readmissions related to infection (sternotomy and general), peripheral vascular complications, and musculoskeletal disorders were more frequent for the CABG group.
In predictive models, the risk of readmission for any cause was higher after PCI, which was considered an independent predictor of readmission due to CV but not non-CV causes. When assessing mortality, all-cause readmission was independently associated with higher all-cause mortality (aHR: 4.02; 95% CI: 2.78-5.81; P <0.0001), cardiovascular mortality (aHR: 3.85; 95% CI: 2.16-6.85; P <0.0001), and non-CV death (aHR: 4.15; 95% CI: 2.57-6.70; P <0.0001) within 5 years of follow-up.
Conclusions
The results of the EXCEL sub-analysis showed a fairly high frequency of readmission, 45.2% of cases, with an intermediate distribution between CV and non-CV causes. When evaluated by strategy, patients assigned to PCI had a higher annualized readmission rate, and PCI was considered an independent factor for readmission.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Incidence, Predictors, and Impact of Hospital Readmission After Revascularization for Left Main Coronary Disease.
Reference: Kosmidou I, Shahim B, Dressler O, Redfors B, Morice MC, Puskas JD, Kandzari DE, Karmpaliotis D, Brown WM 3rd, Lembo NJ, Banning AP, Kappetein AP, Serruys PW, Sabik JF 3rd, Stone GW. Incidence, Predictors, and Impact of Hospital Readmission After Revascularization for Left Main Coronary Disease. J Am Coll Cardiol. 2024 Mar 19;83(11):1073-1081. doi: 10.1016/j.jacc.2024.01.012. PMID: 38479955.
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