PCI for CTO Ups Survival vs. Medical Therapy, CABG

Treatment of chronic total occlusion (CTO) with PCI improves survival and reduces adverse events at 1 year compared with medical therapy and CABG surgery, according to data presented at TCT 2014.

Salvatore D. Tomasello, MD, of University of Catania, Italy, and colleagues conducted a 12-month prospective, phase 1 study using data from the Italian Registry of Chronic Total Occlusion (IRCTO), which enrolled 1,777 patients with at least one CTO (>3 months duration) in a main coronary artery (>2.5 mm diameter) at 12 Italian centers. Those with prior CABG were excluded.

Patients were divided into three study arms based on their treatment strategy: medical therapy (n=826), PCI (n=776) or CABG (n=175). Those managed by medical therapy were older in comparison with the other groups, and they more frequently had chronic lung disease and severely impaired left ventricular ejection fraction. Patients managed with CABG had higher prevalence of three-vessel disease.

Difference still seen after adjustment

One-year rates of MACCE were 2.6% for PCI, 8.2% for medical therapy and 6.9% for CABG (P<.01). Rates of cardiovascular death were 1.4%, 4.7% and 6.3%, respectively (P<.001).

“In the unadjusted results, it seems clear that medical therapy had a higher rate of death, MI and rehospitalization in comparison to patients managed with PCI; surgery had a higher rate of death and stroke in comparison to the other groups,” Tomasello said. “PCI was able to achieve a better outcome in comparison to patients managed with medical therapy or compared to surgery. These [results], of course, may be due to the difference in baseline characteristics.”

Yet on multivariate Cox regression analysis, treatment with CABG or medical therapy and chronic renal failure all were identified as independent predictors of MAACE at 1 year (see Figure). In addition, after propensity score matching, patients treated with PCI rather than medical therapy showed lower rates of death (1.5% vs. 4.4%; P<.001), acute MI (1.1% vs. 2.9%; P=.03) and rehospitalization (2.3% vs. 4.4%; P=.04).

Quality of life vs. prognosis

After hearing the data, session moderator David E. Kandzari, MD, from the Piedmont Heart Institute, Atlanta, Ga., asked about quality of life, stressing that, by his count, this is approximately the fifteenth study to suggest improved survival in utilizing PCI to treat CTO.

“While there is a remarkable theme, or consistency, … we also have to be very cognizant of the benefits of CTO revascularization independent of survival, namely with quality-of-life measures,” Kandzari said, noting that there may be different standards of success for CTO compared with less severely blocked lesions.

Tomasello agreed and — although he did not present data to support these claims — said that the IRCTO researchers did monitor such issues. “We observed an improvement of the symptoms in all the arms of the study,” Tomasello said. However, he emphasized that the goal of CTO treatment should not rest only on improving symptoms, but rather it may be “more important to improve the prognosis of the patient. Maybe we can achieve those results.”

Disclosures:

• Tomasello reports no relevant conflict of interests.

• Kandzari reports relationships with multiple device companies.

• The study was supported by the Italian Society of Invasive Cardiology.