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107 Elective Medical Therapy Versus Angioplasty of Chronic Total Coronary Occlusions: A Propensity Matched Retrospective Cohort Study
  1. Andrew Ladwiniec1,
  2. Victoria Allgar2,
  3. Simon Thackray3,
  4. Farquad Alamgir3,
  5. Angela Hoye2
  1. 1Castle Hill Hospital
  2. 2Hull York Medical School
  3. 3Hull and East Yorkshire Hospitals NHS Trust

Abstract

Introduction An association between improved survival and successful PCI of chronic total coronary occlusions (CTO) when compared with failed PCI has been widely reported. However a comparison between elective medical therapy and CTO PCI is more relevant to clinical decision making. We compared long-term clinical outcomes in a cohort of patients with an identified CTO on angiography between these two treatment groups, hypothesising there would be a difference in all-cause mortality at 5 year follow-up.

Methods Patients found to have a CTO on angiography between 2002 and 2008, without prior CABG or important structural heart disease in a single tertiary centre were identified using a dedicated database. Patients undergoing CTO PCI and elective medical therapy to the CTO were matched using a propensity score to adjust for baseline clinical and angiographic differences. Events at follow-up were identified using national death certification records and national registries for myocardial infarction, CABG and PCI.

Results In total 1957 patients were identified, a CTO was treated by PCI in 405 (20.7%) and medical therapy in 667 (34.1%), 885 (45.2%) patients underwent CABG. Of those treated by PCI or medical therapy, propensity score matching identified 389 pairs of patients. PCI was successful in 238 patients (61.2%). There was no difference in the primary study objective of 5 year mortality between the propensity matched treatment groups (CTO PCI: 10.8%, medical therapy: 15.7%; HR 0.74; 95% CI 0.49 to 1.11; p = 0.146), or after adjustment for Syntax score: (HR 0.81; 95% CI 0.53–1.25; p = 0.336). There remained no difference if only the 238 matched pairs in which CTO PCI was successful were included (HR 0.83; 95% CI 0.48 to 1.42; p = 0.493). There was an increase in repeat revascularisation associated with CTO PCI (HR 2.18; 95% CI 1.49–3.18; p < 0.001). This difference was not present in the successful PCI matched pair subgroup (HR 0.79; 95% CI 0.45–1.37; p = 0.397).

Conclusions Using an alternative approach to much of the existing literature, we have not demonstrated an associated difference in survival between patients with a CTO treated by PCI versus those in whom the CTO was treated medically. Doubt remains as to whether PCI of a CTO should be performed on grounds of prognosis.

Abstract 107 Figure 1

Kaplan-Meier curve showing comparison of 5 year survival between propensity matched groups of patients with an identified CTO treated by elective medical therapy vs. CTO PCI

  • CTO
  • PCI
  • Medical therapy

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