Impact of chronic obstructive pulmonary disease on 10-year mortality after percutaneous coronary intervention and bypass surgery for complex coronary artery disease: insights from the SYNTAX Extended Survival study

Rutao Wang,Kuniaki Takahashi,Yoshinobu Onuma,Chao Gao,David Van Klaveren,Piroze Davierwala ,Francesco Burzotta,Masafumi Ono,Adam Witkowski,Nick Curzen,Daniel J F M Thuijs ,Friedrich W Mohr,Arie Pieter Kappetein,Mariusz Tomaniak,Ling Tao,Hideyuki Kawashima,Hironori Hara,Stefan James,Sérgio Berti ,Stuart J Head,Michael J Mack,Marie Claude Morice ,Robert Jan Van Geuns ,David R Holmes,Patrick W Serruys

doi:10.1007/s00392-021-01833-y

Abstract

AimsTo evaluate the impact of chronic obstructive pulmonary disease (COPD) on 10-year all-cause death and the treatment effect of CABG versus PCI on 10-year all-cause death in patients with three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD) and COPD.MethodsPatients were stratified according to COPD status and compared with regard to clinical outcomes. Ten-year all-cause death was examined according to the presence of COPD and the revascularization strategy.ResultsCOPD status was available for all randomized 1800 patients, of whom, 154 had COPD (8.6%) at the time of randomization. Regardless of the revascularization strategy, patients with COPD had a higher risk of 10-year all-cause death, compared with those without COPD (43.1% vs. 24.9%; hazard ratio [HR]: 2.03; 95% confidence interval [CI]: 1.56–2.64; p < 0.001). Among patients with COPD, CABG appeared to have a slightly lower risk of 10-year all-cause death compared with PCI (42.3% vs. 43.9%; HR: 0.96; 95% CI: 0.59–1.56, p = 0.858), whereas among those without COPD, CABG had a significantly lower risk of 10-year all-cause death (22.7% vs. 27.1%; HR: 0.81; 95% CI: 0.67–0.99, p = 0.041). There was no significant differential treatment effect of CABG versus PCI on 10-year all-cause death between patients with and without COPD (pinteraction = 0.544).ConclusionsCOPD was associated with a higher risk of 10-year all-cause death after revascularization for complex coronary artery disease. The presence of COPD did not significantly modify the beneficial effect of CABG versus PCI on 10-year all-cause death.Trial registration: SYNTAX: ClinicalTrials.gov reference: NCT00114972. SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050Graphic abstract

Highlights

Chronic obstructive pulmonary disease (COPD) is associated with accelerated atherosclerosis and cardiovascular disease; they frequently coexist [1, 2]
COPD was associated with a higher risk of 10-year all-cause death after revascularization for complex coronary artery disease
COPD status was available in all patients randomized in the SYNTAX trial

Summary

Introduction

Chronic obstructive pulmonary disease (COPD) is associated with accelerated atherosclerosis and cardiovascular disease; they frequently coexist [1, 2]. Patients with COPD are perceived to be at increased surgical risk, and are often referred to percutaneous coronary intervention (PCI) instead of coronary bypass artery grafting (CABG). Most studies have demonstrated that COPD patients undergoing CABG had increased in-hospital and long-term mortality [10, 11], whilst some studies reported discrepant results [12, 13]. In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, COPD was associated with worse clinical outcomes after left main coronary artery disease (LMCAD) revascularization. The relative risks of PCI versus CABG at 30 days and 3 years were similar irrespective of the presence of COPD in this specific subset of patients [18]. The optimal revascularization strategy for patients with COPD and complex CAD remains debatable

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Conclusion