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.
- Medical therapy
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