This analysis from the EXCEL trial (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) compared the rates, etiology, and long-term prognostic implications of spontaneous myocardial infarction (MI) after percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery for left main coronary artery disease (LMCAD). Among 1882 patients who underwent LMCAD revascularization, spontaneous MI during 5-year follow-up occurred in 60 (6.8%) patients after PCI and in 29 (3.4%) patients after CABG, with an adjusted hazard ratio (adjHR) of 2.01 (95% CI, 1.29-3.15; p=0.002). By multivariable analysis, spontaneous MI (as a time-adjusted covariate) was a strong independent predictor of subsequent cardiovascular mortality (adjHR, 9.39; 95% CI, 5.22-16.87) and all-cause mortality (adjHR, 4.77; 95% CI, 2.92-7.80) within 5 years, with consistent effects after PCI and CABG (p for interaction = 0.60 and 0.78, respectively). In the same models, procedural MI as defined by extensive myonecrosis was associated with 5-year cardiovascular mortality (adjHR, 3.02; 95% CI, 1.64-5.56) and all-cause mortality (adjHR, 2.38; 95% CI, 1.48-3.80), with consistent effects after PCI and CABG (p for interaction = 0.23 and 0.34, respectively). The study concludes that spontaneous MI occurred relatively infrequently within 5 years after LMCAD revascularization but at a higher rate after PCI compared with CABG. Spontaneous MI after revascularization was strongly related to subsequent cardiovascular and all-cause mortality, consistently after PCI and CABG, and was more strongly associated with mortality than was large procedural MI.
If you have a major blockage in your main heart artery, you might face a choice between two procedures: getting a stent (PCI) or having bypass surgery (CABG). A big question is which one better protects you from having a heart attack in the years that follow. A major trial followed nearly 1,900 patients for five years to find out. It looked specifically at 'spontaneous' heart attacks—the kind that happen out of the blue, not during the procedure itself. The results show these later heart attacks, while not common, happened more often in patients who got a stent (6.8%) compared to those who had bypass surgery (3.4%). More importantly, when a patient did have one of these spontaneous heart attacks, it was a very strong signal of danger. It was linked to a dramatically higher risk of dying from heart problems or any cause within the next five years. This increased risk was true whether the patient originally had a stent or bypass surgery. The study also found that a very large heart attack during the initial procedure was linked to a higher risk of death, but the link was even stronger for a spontaneous heart attack that happened later. The bottom line: the type of procedure you get for this specific blockage can affect your chances of having a dangerous, late-occurring heart attack, which itself is a major red flag for future health.
What this means for you: A heart attack years after treatment for a major blockage is a powerful predictor of death, and happens more often after stents than bypass surgery.
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BACKGROUND: Limited data are available regarding the relative rates, etiology, and long-term prognostic implications of spontaneous myocardial infarction (MI) after percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery for left main coronary artery disease (LMCAD).
METHODS: MIs after PCI and CABG for LMCAD were adjudicated from the EXCEL trial (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). Cox proportional hazards regression was performed to assess the association between spontaneous (and procedural) MI and cardiovascular and all-cause mortality at 5 years.
RESULTS: Among 1882 patients who underwent LMCAD revascularization, spontaneous MI during 5-year follow-up occurred in 60 (6.8%) patients after PCI and in 29 (3.4%) patients after CABG (adjusted hazard ratio [adjHR], 2.01; 95 CI, 1.29-3.15; =0.002). By multivariable analysis, spontaneous MI (as a time-adjusted covariate) was a strong independent predictor of subsequent cardiovascular mortality (adjHR, 9.39; 95% CI, 5.22-16.87) and all-cause mortality (adjHR, 4.77; 95% CI, 2.92-7.80) within 5 years, with consistent effects after PCI and CABG (=0.60 and 0.78, respectively). In the same models, procedural MI as defined by extensive myonecrosis was associated with 5-year cardiovascular (adjHR, 3.02; 95% CI, 1.64-5.56) and all-cause mortality (adjHR, 2.38; 95% CI, 1.48-3.80), with consistent effects after PCI and CABG (=0.23 and 0.34, respectively).
CONCLUSIONS: In the EXCEL trial, spontaneous MI occurred relatively infrequently within 5 years after LMCAD revascularization but at a higher rate after PCI compared with CABG. Spontaneous MI after revascularization was strongly related to subsequent cardiovascular and all-cause mortality, consistently after PCI and CABG, and was more strongly associated with mortality than was large procedural MI.
REGISTRATION: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01205776.