Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC nXF5zbfScpMqTJShJWsXkrS S0066-782X2017001400466 10.5935/abc.20170153 Original Articles Comparison of Secondary Prevention Status between Percutaneous Coronary Intervention and Coronary Artery Bypass Patients Gao Xia-qing 1 2 LI Yanfang 1 2 Jiang Zhi-li 1 2 Capital Medical University Beijing Anzhen Hospital Beijing China Beijing Anzhen Hospital - Capital Medical University, Beijing - China Beijing Institute of Heart Lung and Blood Vessel Diseases Beijing China Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing - China Mailing Address: Yanfang LI • Beijing Anzhen Hospital of Capital Medical University, Anzhen Street. 100029, Beijing - China. E-mail: 422655835@qq.com

Author contributions

Conception and design of the research and Acquisition of data: Xia-qing Gao, Yan-fang Li, Zhi-li Jiang; Analysis and interpretation of the data and Writing of the manuscript: Xia-qing Gao; Statistical analysis: Xia-qing Gao, Zhi-li Jiang; Obtaining financing and Critical revision of the manuscript for intellectual content: Yan-fang Li.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

 11 2017 109 5 466 474 23 01 2017 13 06 2017 13 06 2017 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background:

Data are scarce regarding disparities in cardiovascular risk factor management between patients treated with percutaneous coronary intervention (PCI) and those treated with coronary artery bypass grafting (CABG).

 Objective:

Whether the goal achievement rates of cardiovascular risk factors were different between PCI and CABG patients.

 Methods:

We retrospectively reviewed the data retrieved from a clinical record database of patients admitted to Beijing Anzhen Hospital between January 1, 2014, and December 31, 2014, who underwent PCI or CABG.

 Results:

Compared with the CABG group, low-density lipoprotein cholesterol (LDL-C) < 1.8 mmol/L (28.6% vs. 24.7%; p < 0.01), LDL-C < 2.07 mmol/L (43.5% vs. 39.4%; p < 0.01) and blood pressure (BP) < 140/90 mm Hg (85.6% vs. 77.7%; p < 0.01) goal achievement rates were significantly higher in the PCI group. Compared with patients ≥ 60 years old: patients < 60 years old had better BP < 140/90 mm Hg goal achievement rates (87.7% vs. 84.4%; p < 0.01) in the PCI group, and better fasting blood-glucose (FBG) < 7 mmol/L (79.4% vs.72.0%; p < 0.01) and HbA1c < 7% (79.4% vs. 70.1%; p < 0.01) goal achievement rates in the CABG group. Compared with females: males had better LDL-C < 2.07 mmol/L (24.7% vs. 28.5%; p < 0.01), FBG < 7 mmol/L (71.8% vs.75.2%; p < 0.01) and HbA1c < 7% (70.4% vs. 74.1%; p < 0.01) goal achievement rates in the PCI group.

 Conclusion:

Patients in the PCI group were generally more likely than those in the CABG group to achieve LDL-C < 1.8 mmol/L and BP goals. The control of cardiovascular risk factors differed between patients ≥ 60 years old and < 60 years old. Female patients were less likely to achieve LDL-C, FBG and HbA1c goals.

 Keywords Percutaneous Coronary Intervention Coronary Artery Bypass Myocardial Revascularization Risk Factors National Nature Science Foundaction of China 81270380 This study was funded by National Nature Science Foundaction of China (Nº. 81270380). Introduction

In China, the number of patients who undergo coronary revascularization increases with cardiovascular disease outbreaks. Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are two major coronary revascularization procedures. Although PCI and CABG have saved plenty of lives, they do not prevent the progression of arterial atherosclerosis, and major events and secondary revascularization rates remain high in patients 5 years later.1 Taking secondary preventive drugs is important for those patients.2,3

Roughly 14,000 patients underwent CABG or PCI in Beijing Anzhen Hospital every year. However, in practice, we found that cardiovascular physicians and cardiothoracic surgeons have different concerns with respect to long-term prognosis, which might influence the prescription of secondary preventive drugs and further leads to unbalanced control of coronary artery disease (CAD)-related risk factors, such as LDL-C, blood pressure (BP), fasting blood-glucose (FBG), and hemoglobin A1c (HbA1c), in PCI and CABG patients. In addition, previous studies have reported that the control of cardiovascular risk factors was different in different age groups and different sex. We hypothesized that patients who have undergone CABG would be less likely than patients who have undergone PCI to achieve lipid, FBG, HbA1c and BP goals. We assessed the goal attainment and clinical outcomes in PCI and CABG patients, and the goal achievement rates in patients ≥ 60 years old and < 60 years old, females and males.

 Methods Source population

This retrospective study enrolled 14,230 patients who underwent PCI (n = 9,866) or CABG (n = 4,364) in Beijing Anzhen Hospital between January 1, 2014, and December 31, 2014. The index date was that of the revascularization procedure. We excluded patients (n = 7,707) aged < 18 years with a history of coronary revascularization, malignant tumor, multiple organ dysfunction syndrome, or organ transplantation, without complete demographic data, without continued drug prescription record, or whose second lipid level values were not available after the index date. A total of 6,523 patients were ultimately included in the analysis and matched by propensity score.

 Data collection

Clinical information was retrieved from computerized clinical records, and relevant clinical data were extracted up to December 31, 2015, the start of the data collection period. We obtained the following data: age; sex; history of present illness; comorbidities (hypertension, diabetes, stroke, peripheral vascular disease, chronic kidney disease); cardiovascular disease-related risk factors (smoking, drinking, obesity); coronary artery lesions (SYNTAX score); lipid, BP, FBG and HbA1c levels before discharge and during follow-up. Date of cardiac death, recurrent acute coronary syndrome (ACS), stroke, non-fatal acute myocardial infarction (AMI), and revascularization were also collected for the patient outcome analysis. Composite endpoints were defined as cardiac death, recurrent ACS, and stroke. Recurrent ACS was defined as recurrent non-fatal AMI and unstable angina. Lipid, BP, FBG and HbA1c levels before discharge were defined as lipid, BP, FBG and HbA1c levels before the coronary revascularization procedure, while lipid, BP, FBG and HbA1c levels during follow-up were defined as the most recently lipid, BP, FBG and HbA1c levels (at least 3 months after discharge) if there was no endpoint event, and lipid, BP, FBG and HbA1c levels during re-hospitalization if there was an endpoint event. Hypertension, diabetes, dyslipidemia, stroke, peripheral vascular disease, chronic kidney disease, alcohol heavy drinking, and obesity were defined as published previously.4 The follow-up period of each individual from the discharge date until December 31, 2015, was also calculated. Lipid goal attainment was defined as an LDL-C < 1.8 mmol/L (70 mg/dL) and non-high-density lipoprotein cholesterol (HDL-C) < 2.6 mmol/L (100 mg/dL),5 or LDL-C < 2.07 mmol/L (80 mg/dL) and non-HDL-C < 2.8 mmol/L (110 mg/dL).6 The FBG goal attainment was defined as FBG < 7.0 mmol/L; HbA1c < 7%. Blood pressure goal attainment was defined as BP < 140/90 mm Hg.7

This study was approved by the Beijing Anzhen Hospital Ethics Committee.

 Statistical methods

Propensity scores were estimated using a multiple logistic regression analysis. PCI and CABG patients were 1:1 matched using the nearest neighbor matching method. Continuous variables with normal distribution were presented as mean ± standard deviation, and those with non-normal distribution were presented as median and interquartile range. Categorical variables were depicted as absolute numbers and percentages. K-S test was used to verify the normality of the data. Continuous variables were compared using the Wilcoxon signed rank test or a paired t test, and categorical variables were compared using the chi-square test. Kaplan-Meier survival curves were used to compare the cumulative incidence of composite endpoint events. Cox regression analysis was performed to evaluate the influence of baseline covariates on composite outcomes. The log-rank test was performed before Cox regression. Variables with P values ≤ 0.10 were candidates for the multivariate model. Covariates included in Cox regression analysis were as follows: age, sex, hypertension, diabetes mellitus, dyslipidemia, smoking, stroke, peripheral artery disease, chronic kidney disease, body mass index (BMI), left ventricular ejection fraction (EF), SYNTAX score, and achievement of LDL-C, FBG, HbA1c and BP goals. All analyses were performed with SPSS (version 22.0; IBM, Armonk, NY, USA). All tests were two-tailed, and P values < 0.05 were considered statistically significant.

 Results Baseline characteristics

A total of 6,523 (PCI = 4,728; CABG = 1,795) patients were enrolled in the study. Compared to patients in the PCI group, those in the CABG group were older and more likely to have a history of diabetes and stroke; less likely to have a history of hypertension, and dyslipidemia; and presented lower BMI, HDL-C level and left ventricular EF, and higher SYNTAX score. A total of 1,790 matched patient pairs were created after propensity-score matching was performed for the entire population. The baseline characteristics did not differ significantly between the PCI and CABG groups after the propensity-score matching (Table 1).

Baseline characteristics of patients in PCI and CABG groups
Total population Propensity-matched population
PCI n = 4728 CABG n = 1795 p value PCI n = 1790 CABG n = 1790 p value
Age (years) 58.9 ± 10.2 61.9 ± 9.0 < 0.01 62.0 ± 9.9 61.9 ± 9.0 0.68
Sex (male) 3499(74.0) 1353(75.4) 0.26 1369(76.5) 1349(75.4) 0.43
Hypertension 2394(61.2) 1073(59.8) < 0.01 1068(59.6) 1072(59.9) 0.87
Diabetes 1461(30.9) 634(35.3) 0.001 632(35.3) 630(35.5) 0.94
Dyslipidemia 3749(79.3) 1361(75.8) 0.002 1360(76.0) 1348(75.3) 0.64
Stroke 265(5.6) 169(9.4) < 0.01 150(8.4) 168(9.4) 0.29
PVD 52(1.1) 23(1.3) 0.54 27(1.5) 23(1.3) 0.57
CKD 33(0.7) 9(0.5) 0.38 7(0.4) 9(0.5) 0.62
Smoking 2392(50.6) 863(48.1) 0.07 848(47.4) 863(48.2) 0.62
BMI 26.5 ± 3.4 25.4 ± 2.9 < 0.01 25.3 ± 3.3 25.4 ± 2.9 0.57
LVEF (%) 62.2 ± 8.3 60.4 ± 9.0 < 0.01 60.7 ± 9.1 60.5 ± 9.0 0.50
SYNTAX score 23.4 ± 9.3 28.1 ± 10.1 < 0.01 27.8 ± 9.3 28.0 ± 10.2 0.19
Lipid levels before discharge (mmol/L)
TC 4.58 ± 0.9 4.57 ± 1.1 0.87 4.56 ± 1.0 4.57 ± 1.1 0.82
TG 1.87 ± 1.2 1.83 ± 1.1 0.24 1.83 ± 1.1 1.83 ± 1.1 0.99
LDL-C 2.86 ± 0.8 2.88 ± 0.9 0.52 2.87 ± 0.8 2.88 ± 0.9 0.75
HDL-C 1.00 ± 0.2 0.97 ± 0.2 < 0.01 0.97 ± 0.2 0.97 ± 0.2 0.56
FBG (mmol/L) and HbA1c (%) levels before discharge
FBG 6.08 ± 1.7 5.77 ± 1.5 0.07 5.91 ± 1.6 5.77 ± 1.5 0.36
HbA1c 5.93 ± 1.1 5.78 ± 1.1 0.17 5.80 ± 1.1 5.78 ± 1.1 0.64
Blood pressure (mmHg) before discharge
SBP 127.65 ± 15.4 124.04 ± 17.7 0.13 124.5 ± 16.3 124.04 ± 17.7 0.91
DBP 76.54 ± 11.3 75.35 ± 10.6 0.04 75.04 ± 10.3 75.35 ± 10.6 0.32

Values are presented as mean±standard deviation and median with interquartile range or n (%); PCI: percutaneous coronary intervention; CABG: coronary artery bypass grafting; PVD: peripheral vascular disease; CKD: chronic kidney disease; BMI: body mass index; LVEF: left ventricular ejection fraction; TC: total cholesterol; TG: triglyceride; LDL-C: low density lipoprotein cholesterol; HDL-C: high density lipoprotein cholesterol; FBG: fasting blood-glucose; HbA1c: hemoglobin A1C; SBP: systolic blood pressure; DBP: diastolic blood pressure.

 LDL-C, FBG, HbA1c, and BP goal attainment rates in total and propensity matched PCI and CABG patients

Compared with the CABG group, LDL-C < 1.8 mmol/L, LDL-C < 2.07 mmol/L and BP < 140/90 mmHg goal achievement rates in the PCI group were significantly higher in the unmatched patients after discharge. The FBG and HbA1C target attainment rates did not differ significantly between the two groups after discharge (Table 2). In propensity matched patients, LDL-C < 1.8 mmol/L, LDL-C < 2.07 mmol/L and BP < 140/90 mmHg goal achievement rates in the PCI group were significantly higher than in the CABG group. The FBG and HbA1c goal achievement rates were not significantly different between the two groups (Table 2).

LDL-c, FBG, HbA1c, and BP goal achievement rates in PCI and CABG groups
Total population Propensity-matched population
Risk factor goals PCI CABG p PCI CABG p
LDL-c <1.8 mmol/La 1352(28.6) 443(24.7) 0.002 522(29.2) 442(24.7) 0.003
LDL-c < 2.07 mmol/Lb 2055(43.5) 708(39.4) 0.003 787(44.0) 707(39.5) 0.007
FBG < 7 mmol/Lc 3498(74.2) 1342(74.8) 0.492 1361(76.0) 1342 (75.0) 0.46
HbA1c < 7%c 3456(73.1) 1321(73.6) 0.686 1349(75.4) 1319(73.7) 0.25
BP < 140/80 mmHgd 4049(85.6) 1394(77.7) 0.000 1525(85.2) 1391(77.7) 0.000

Values are presented as n (%);

,Chinese guidelines on prevention and treatment of dyslipidemia in adults, 2007;

,ESC/EAS guidelines for the management of dyslipidaemias, 2011;

,Chinese guidelines on type 2 diabetes prevention and treatment, 2013;

,Chinese guidelines on prevention and treatment of hypertension, 2011. PCI: percutaneous coronary intervention; CABG: coronary artery bypass grafting; LDL-C: low density lipoprotein cholesterol; FBG: fasting blood-glucose; HbA1c: hemoglobin A1C; BP: blood pressure.

 Clinical outcomes

In unmatched patients, composite endpoint rates were significantly higher in the PCI group than in the CABG group (Table 4). The median follow-up duration was 10.99 months. In propensity matched patients, composite endpoint rates were not significantly different between the two groups (Figure 1, Table 4). Recurrent ACS rates were significantly higher in the PCI group than in the CABG group in both matched and unmatched patients (Table 4). Stroke incidence was significantly higher in the CABG group than in the PCI group (Table 4). On multivariable Cox regression analysis, LDL-C < 1.8 mmol/L and HbA1c < 7% were independent predictors of composite endpoints in the unmatched overall, PCI, and CABG patients, hazard ratio were reduced in those patients who achieved goals (Table 3). To determine whether the composite endpoint rates in the matched patients according to PCI and CABG were consistent, we applied subgroup analysis. Compared with patients in the PCI group, patients in the CABG group had better clinical outcome regarding diabetes and obesity, and patients ≥ 60 years old subgroups (Figure 2).

Independent predictors of composite endpoints in PCI and CABG groups
Overall ICP CRM
Variables HR 95% CI p HR 95% CI p HR 95% CI p
Sexa 0.298 (1.08-1.68) 0.008 0.251 (1.01-1.64) 0.043 0.414 (0.87-2.64) 0.144
PCI vs CABG 0.821 (1.81-2.85) 0.000
Smokinga 1.692 (1.29-2.72) 0.000 1.783 (1.43-3.13) 0.000 1.113 (0.98-1.81) 0.754
LDL-c < 1.8 -2.197 (0.07-0.17) 0.000 -2.329 (0.06-0.16) 0.000 -1.023 (0.09-0.45) 0.000
HbA1c < 7% -0.363 (0.58-0.85) 0.000 -0.403 (0.54-0.82) 0.000 -0.392 (0.53-0.88) 0.000
EF < 40%b -0.241 (0.52-1.19) 0.252 -0.101 (0.56-1.47) 0.686 -0.825 (0.20-0.95) 0.037
Dyslipidemiac 1.164 (0.96-1.45) 0.120 1.256 (1.03-1.63) 0.030 1.09 (0.59-1.43) 0.679
BP < 140/80 mmHg -0.475 (0.32-0.49) 0.000 -0.432 (0.37-0.50) 0.000 -0.129 (0.39-1.76) 0.788

Values are presented as n (%); CI: confidence interval; HR: Hazard ratio;

sex and smoke were significant predictors in overall and PCI-treated patients;

EF > 40% was a significant predictor in CABG-treated patients;

dyslipidemia was a significant predictor in PCI-treated patients. PCI: percutaneous coronary intervention; CABG: coronary artery bypass grafting; LDL-C: low density lipoprotein cholesterol; HbA1c: hemoglobin A1C; EF: ejection fraction; BP: blood pressure.

 Clinical outcomes in PCI and CABG groups
Total population Propensity-matched population
PCI CABG HR(95% CI) p PCI CABG HR(95% CI) p
Composite endpoints 424(9.0) 101(5.6) 1.652(1.32.2.07) 0.000 126(7.0) 101(5.6) 1.27 (0.97.1.66) 0.09
Recurrence ACS 389(8.2) 80(4.5) 5.935(4.619.7.626) 0.000 116(6.5) 80(4.5) 1.48(1.11.1.99) < 0.01
Stroke 29(0.6) 19(1.1) 1.535(0.858.2.748) 0.146 8(6.4) 19(1.1) 0.42(0.18.0.96) 0.03
Cardiac death 6(0.1) 2(0.1) 3.007(0.606.14.917) 0.157 2(0.1) 2(0.1) 1.00(0.14.7.11) 1.00

Values are presented as n (%). Composite end points included recurrent ACS, stroke and cardiac death. ACS: acute coronary syndrome. PCI: percutaneous coronary intervention.

Kaplan-Meier cumulative events for composite endpoint. Composite endpoint events (cardiac death/recurrent acute coronary syndrome/stroke) rate were not significantly different between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) patients.

Comparative unadjusted hazard ratios of recurrent ACS for subgroups in propensity-matched populations of the percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) groups. CI: confidence interval; BMI: body mass index; ACS: acute coronary syndrome.

LDL-C, FBG, HbA1c, and BP goal attainment rates in unmatched patients with different ages

In unmatched overall and PCI patients, compared with patients ≥ 60 years old: patients < 60 years old had better BP < 140/90 mm Hg goal achievement rates and worse LDL-C < 2.07 mmol/L goal achievement rates. The LDL-C < 1.8 mmol/L, FBG < 7 mmol/L, and HbA1c < 7% goal achievement rates were not significantly different. In unmatched CABG patients, compared with patients ≥ 60 years old: patients < 60 years old had better FBG < 7 mmol/L, HbA1c < 7%, BP < 140/90 mm Hg goal achievement rates, the LDL-C < 1.8 mmol/L and LDL-C < 2.07 mmol/L goal achievement rates were not significantly different between the two groups (Table 5).

LDL-c, FBG, HbA1c, and BP goal achievement rates in different age and sex
Overall PCI CABG
LDL-c, FBG, HbA1c, and BP goal achievement rates in patients who < 60 and ≥ 60 year old
Risk factor goals < 60 ≥ 60 p < 60 ≥ 60 p < 60 ≥ 60 p
LDL-c < 1,8 mmol/La 640(26.3) 1155(28.3) 0.079 474(27.0) 878(29.6)†† 0.056 166(24.4) 277(24.8) 0.859
LDL-c < 2,07 mmol/Lb 967(39.7) 1796(44.0) 0.001 703(40.0) 1352(45.5) †† 0.001 264(38.9) 444(39.8) 0.704
FBG < 7 mmol/Lc 1817(74.5) 3023(74.0) 0.608 1278(72.8) 2219(74.7) 0.138 539(79.4)‡‡ 804(72.0) 0.001
HbA1c < 7%c 1805(72.9) 2972(72.7) 0.240 1266(72.0) 2190(73.7) † 0.196 539(79.4) ‡‡ 782(70.1) 0.001
BP < 140/80 mmHgd 2093(85.9) 3350(82.0) 0.000 1541(87.7)* 2508(84.4) †† 0.002 552(81.3) 842(75.4) 0.004
LDL-c, FBG, HbA1c, and BP goal achievement rates in female and male
Risk factor goals Female Male p Female Male p Female Male p
LDL-c < 1,8 mmol/La 399(24.7) 1396(28.5) 0.003 306(25.5) 1046(29.6) 0.006 93(22.2) 350(25.4) 0.188
LDL-c < 2,07 mmol/Lb 661(40.9) 2102(42.8) 0.165 502(41.9) 1553(44.0) 0.197 159(38.0) 549(39.9) 0.502
FBG < 7 mmol/Lc 1152(71.8) 3689(75.2) 0.002 851(71.0) 2647(75.0) 0.006 301(72.0) 1042(75.7) 0.131
HbA1c < 7%c 1139(70.4) 3638(74.1) 0.003 832(69.4) 2624(74.4) 0.001 307(73.4) 1014(73.6) 0.937
BP < 140/80 mmHgd 1330(82.3) 4113(83.8) 0.137 1019(85.0) 3030(85.9) 0.457 311(74.4) 1083(78.6) 0.068

Values are presented as n (%);

Chinese guidelines on prevention and treatment of dyslipidemia in adults, 2007;

ESC/EAS guidelines for the management of dyslipidemia, 2011;

Chinese guidelines on type 2 diabetes prevention and treatment, 2013;

d Chinese guidelines on prevention and treatment of hypertension, 2011;

in patients who < 60, compared with CABG group, p < 0.01;

in patients who ≥ 60, compared with CABG group, p < 0.01;

in patients who ≥ 60, compared with CABG group, p < 0.05;

in patients who < 60, compared with PCI group, p < 0.01. PCI: percutaneous coronary intervention; CABG: coronary artery bypass grafting; LDL-C: low density lipoprotein cholesterol; FBG: fasting blood-glucose; HbA1c: hemoglobin A1C; BP: blood pressure.

 LDL-C, FBG, HbA1c, and BP goal attainment rates in unmatched patients of different sexes

In unmatched overall and PCI patients, compared with females: males had better LDL-C < 1.8 mmol/L, FBG < 7 mmol/L, and HbA1c < 7% goal achievement rates. The LDL-C < 2.07 mmol/L and BP < 140/90 mmHg goal achievement rates were not significantly different. Those goal achievement rates were not significantly different in CABG patients between females and males (Table 5).

 LDL-C, FBG, HbA1c, and BP goal attainment rates in unmatched patients with different ages and different sexes

In unmatched patients ≥ 60 years old, compared with females, males had better LDL-C < 1.8 mmol/L, FBG < 7 mmol/L, and HbA1c < 7% goal achievement rates. The LDL-C < 2.07 mmol/L and BP < 140/90 mmHg goal achievement rates were not significantly different. Those goal achievement rates were not significantly different in patients < 60 years old between females and males (Table 6).

LDL-c, FBG, HbA1c, and BP goal achievement rates between different sex in patients < 60 years old and patients ≥ 60 years old
Risk factor goals < 60 ≥ 60
Female Male p Female Male p
LDL-c < 1,8 mmol/La 81(24.5) 559(26.5) 0.426 318(24.7) 837(29.9) 0.001
LDL-c < 2,07 mmol/Lb 120(36.3) 847(40.2) 0.171 541(42.1) 1255(44.8) 0.100
FBG < 7 mmol/Lc 239(72.2) 1578(74.9) 0.290 913(71.0) 2111(75.4) 0.003
HbA1c < 7%c 232(70.1) 1573(74.7) 0.076 907(70.5) 2065(73.8) 0.032
BP < 140/80 mmHgd 277(83.7) 1816(86.2) 0.217 1053(81.9) 2297(82.0) 0.905

Values are presented as n (%). LDL-C: low density lipoprotein cholesterol; FBG: fasting blood-glucose; HbA1c: hemoglobin A1C; BP: blood pressure

 Discussion

PCI and CABG techniques were developed rapidly in the late 90s in China. The surgical volume of PCI was increased by 30%-50% per year, and up to 567583 in 2015, forefront in the world. With the improvement of surgical techniques, mortality of CABG was reduced greatly, and was acceptable by an increasing number of patients. Although PCI and CABG successfully saved plenty of lives, how to decrease the incidence of revascularization is a major problem at present. Therefore, the emphasis of secondary prevention is particularly important after PCI and CABG.

In the present study, our major findings are as follows: (a) in overall and the propensity score-matched patients, lipid and BP goal attainment rates were different between PCI and CABG patients; however, LDL-C, FBG, HbA1c and BP goal attainment rates were not optimistic in either group, (b) the LDL-C and BP goal achievement rates in the PCI group, and the FBG and HbA1c goal achievement rates in the CABG group were different between patients < 60 years old and those ≥ 60 years old; (c) the LDL-C, FBG and HbA1c goal achievement rates were significantly lower in females in the PCI group, as well as in patients ≥ 60 years old.

LDL-C and BP goal achievement rates in the PCI group were significantly higher than in the CABG group, and a possible reason might be the difference in medication use and adherence. Hlatky et. al have observed that medication possession ratios of secondary preventive drugs were significantly lower in CABG patients than in PCI patients, and the use of statins was significantly lower in CABG patients than in PCI patients.8 Possible reasons for such disparities might be as follows: (a) in our hospital, some patients after CABG were taken care of by surgeons, treatment strategies differed between cardiologists and cardiothoracic surgeons. Cardiologists followed guidelines and had better performance in using preventive drugs than cardiothoracic surgeons, while cardiothoracic surgeons usually pay more attention to whether the surgery was successful, postoperative complications and wound repair situations rather than secondary prevention drug prescription and health education before discharge;4 (b) some other patients might be followed up by cardiologists after CABG in the outpatient clinic, however, cardiologists may have been trained to consider CABG as a more effective or complete treatment, leading to the neglect of long-term secondary prevention; and (c) patients might feel that a CABG is the definitive treatment for their CAD and that medications are no longer necessary, making them less likely to visit doctors in outpatient clinics and take useful suggestions from them.9 The FBG and HbA1c goal achievement rates were low and were not significantly different between the PCI and the CABG group. Only almost less than one third of all diabetic patients achieved their FBG and HbA1c goals. Hypoglycemic drugs do not belong to the optimal medical therapy (OMT) drugs, sometimes the cardiologists just focused on the OMT treatment and ignored the FBG control; another reason might be that diabetic patients were recommended to go to endocrinology outpatient clinics by cardiologists and cardiothoracic surgeons, but these patients were always less likely to visit another outpatient clinic since they thought they already had one.

In spite of the disparities between PCI and CABG patients in cardiovascular risk factor control, the achievement rates of LDL-C, FBG, HbA1c and BP goals remain low in the PCI group. Possible reason might be that interventional cardiologists are usually more conditioned to consider dual antiplatelet therapy (DAPT) issues and sometimes ignore the use of other secondary prevention drugs.

In our study, composite endpoints were significantly higher in the un-matched PCI group than in the CABG group. This was consistent with previous studies which suggested that patients who underwent CABG had better clinical outcomes than those who underwent PCI.10,11 In the propensity-matched patients, although the recurrent ACS rate was significantly higher in the PCI group, composite endpoints were not significantly different between the two groups. In our multivariate Cox regression analysis, sex, smoking, and achieved LDL-c, HbA1c, and BP goals were independent predictors for composite endpoints in PCI patients, while EF>40%, achieved LDL-c, and BP goals were independent predictors for composite endpoints in CABG patients. The LDL-c and BP goal achievement rates were significantly higher in the PCI group, the HbA1c target attainment rate, although not significantly different, was better in the propensity matched PCI group. The results suggested that secondary prevention was important in reducing post-revascularization events. In the propensity matched subgroup analysis, patients with diabetes, obesity, and ≥ 60 years old had better clinical outcome in the CABG group, in accordance with former studies.12-14

The LDL-C < 2.07 mmol/L goal attainment rate of ACS patients in the DYSIS-China study was 29.7%. In our study, it was significantly improved, but remain very low in PCI and CABG patients. Baseline LDL-C levels were reported to be lower in Chinese ACS patients than in western countries' ACS patients in previous studies.15,16 LDL-C was recommended to be lower than 2.07 mmol/L in Chinese lipid management guideline. Whether the target LDL-C should be in accordance with that of western countries lipid management guidelines (LDL-C < 1.8 mmol/L) remains controversial. Lee et al. have observed that, compared with LDL-C < 2.6 mmol/L, an LDL-C < 1.8 mmol/L did not improve survival in ACS patients.17 However, in our study, achieving the LDL-C < 1.8 mmol/L goal was an independent predictor of decreased composite endpoint risk,18 which suggests that the LDL-C goal of Chinese lipid management guideline in the future should be consistent with that of western countries.

In the PCI group, BP goal achievement rate was higher in patients < 60 years old than those ≥ 60 years old, the FBG and HbA1c goal achievement rates were higher in patients < 60 years old in the CABG group. The results were consistent with those of previous studies that older patients always underuse the recommended secondary preventive drugs and always had bad adherence to those drugs,19 which further lead to worse risk factor target attainment. However, the LDL-C goal achievement was much better in patients ≥ 60 years old. The result differed from most of the former studies, but was consistent with that of Rajendran et al.,20 who found that older patients more often achieved lipid target than younger patients. The results may suggested that the clinicians in our hospital are realizing the importance of statin treatment with each passing day. Hogh et al.,21 have discovered that age-related differences in using secondary prevention drugs have been reduced or even eliminated, which suggested that the disparities in risk factor target attainment will also be eliminated over time. Why the risk factor target attainment was inconsistent between PCI and CABG in different age groups remains unclear, but the results suggested that we should pay more attention to older patients in secondary prevention.

Females were considered to be less likely to achieved their cardiovascular risk factor targets since they were less likely to take secondary preventive drugs due to many reasons. For example, the lowering estrogen levels, higher adverse events and poor adherence might have influence on drug use.22 However, in the study by Jankowski et al.,23 they have found that the frequency of achieving recommended goals in secondary prevention were not sex-related. In our study, the LDL-C, FBG, and HbA1c goal achievement rates were significantly higher in males than in females in the PCI group and in patients ≥ 60 years old. The result suggested that we should pay attention to older women during the secondary prevention process and make sure they are given the optimal treatment.

Limitations of the study

Our study had several limitations. Firstly, it was a single-center observational study performed at a major cardiovascular hospital in China, and the clinical strategies of physicians and surgeons may differ from those of other hospitals in China. Secondly, although propensity score matching was performed to adjust for potential confounding factors in PCI and CABG patients, initial selection bias and unmeasured variables exist.

 Conclusion

Our research showed that there are disparities between PCI and CABG patients in CAD-related risk factor target attainment. Secondary prevention is critical in reducing post-revascularization endpoints. The risk factor target attainment also differed between patients ≥ 60 years old and < 60 years old, females and males, which suggested that cardiologists and cardiothoracic surgeons should pay more attention to those special patients and make correct clinical decisions in the secondary prevention process, which can further ensure those patients have a better prognosis and greater clinical benefits.

Sources of Funding

This study was funded by National Nature Science Foundaction of China (Nº. 81270380).

Study Association

This study is not associated with any thesis or dissertation work.

 References 1 Shiomi H, Morimoto T, Furukawa Y, Nakagawa Y, Tazaki J, Sakata R, et al; CREDO-Kyoto PCI/CABG Registry Cohort-2 Investigators. Comparison of five-year outcome of percutaneous coronary intervention with coronary artery bypass grafting in triple-vessel coronary artery disease (from the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2). Am J Cardiol. 2015;116(1):59-65. doi: 10.1016/j.amjcard.2015.03.040. Shiomi H Morimoto T Furukawa Y Nakagawa Y Tazaki J Sakata R CREDO-Kyoto PCI/CABG Registry Cohort-2 Investigators Comparison of five-year outcome of percutaneous coronary intervention with coronary artery bypass grafting in triple-vessel coronary artery disease (from the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2) Am J Cardiol 2015 116 1 59 65 10.1016/j.amjcard.2015.03.040 2 Iqbal J, Zhang YJ, Holmes DR, Morice MC, Mack MJ, Kappetein AP, et al. Optimal medical therapy improves clinical outcomes in patients undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting: insights from the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial at the 5-year follow-up. Circulation. 2015;131(14):1269-77. doi: 10.1161/CIRCULATIONAHA. Iqbal J Zhang YJ Holmes DR Morice MC Mack MJ Kappetein AP Optimal medical therapy improves clinical outcomes in patients undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting: insights from the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial at the 5-year follow-up Circulation 2015 131 14 1269 1277 10.1161/CIRCULATIONAHA 3 Quin JA, Hattler B, Bishawi M, Baltz J, Gupta S, Collins JF, et al. Impact of lipid-lowering medications and low-density lipoprotein levels on 1-year clinical outcomes after coronary artery bypass grafting. J Am Coll Surg. 2013;217(3):452-60. doi: 10.1016/j.jamcollsurg.2013.04.030. Quin JA Hattler B Bishawi M Baltz J Gupta S Collins JF Impact of lipid-lowering medications and low-density lipoprotein levels on 1-year clinical outcomes after coronary artery bypass grafting J Am Coll Surg 2013 217 3 452 460 10.1016/j.jamcollsurg.2013.04.030 4 Pomeshkina SA, Borovik IV, Zavyrylina IN, Kagan ES, Barbarash OL. [Adherence to therapy as a factor determining prognosis of coronary artery bypass grafting]. Kardiologiia. 2015;55(5):48-53. PMID: 26615624. Pomeshkina SA Borovik IV Zavyrylina IN Kagan ES Barbarash OL [Adherence to therapy as a factor determining prognosis of coronary artery bypass grafting] Kardiologiia 2015 55 5 48 53 26615624 5 Catapano AL, Reiner Z, De Backer G, Graham I, Taskinen MR, Wiklund O, et al; European Society of Cardiology (ESC); European Atherosclerosis Society (EAS). ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis. 2011;217(1):3-46. PMID: 21882396. Catapano AL Reiner Z De Backer G Graham I Taskinen MR Wiklund O European Society of Cardiology (ESC); European Atherosclerosis Society (EAS) ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) Atherosclerosis 2011 217 1 3 46 21882396 6 Joint Committee for Developing Chinese guidelines on Prevention and Treatment of Dyslipidemia in Adults. [Chinese guidelines on prevention and treatment of dyslipidemia in adults]. Zhonghua Xin Xue Guan Bing Za Zhi. 2007;35(5):390-419. PMID: 17711682. Joint Committee for Developing Chinese guidelines on Prevention and Treatment of Dyslipidemia in Adults [Chinese guidelines on prevention and treatment of dyslipidemia in adults] Zhonghua Xin Xue Guan Bing Za Zhi 2007 35 5 390 419 17711682 7 Liu LS; Writing Group of 2010 Chinese Guidelines for the Management of Hypertension. [2010 Chinese guidelines for the management of hypertension]. Zhonghua Xin Xue Guan Bing Za Zhi. 2011;39(7):579-615. PMID: 22088239. LS Liu Writing Group of 2010 Chinese Guidelines for the Management of Hypertension [2010 Chinese guidelines for the management of hypertension] Zhonghua Xin Xue Guan Bing Za Zhi 2011 39 7 579 615 22088239 8 Hlatky MA, Solomon MD, Shilane D, Leong TK, Brindis R, Go AS. Use of medications for secondary prevention after coronary bypass surgery compared with percutaneous coronary intervention. J Am Coll Cardiol. 2013;61(3):295-301. doi: 10.1016/j.jacc.2012.10.018. Hlatky MA Solomon MD Shilane D Leong TK Brindis R Go AS Use of medications for secondary prevention after coronary bypass surgery compared with percutaneous coronary intervention J Am Coll Cardiol 2013 61 3 295 301 10.1016/j.jacc.2012.10.018 9 Riley RF, Don CW, Aldea GS, Mokadam NA, Probstfield J, Maynard C, et al. Recent trends in adherence to secondary prevention guidelines for patients undergoing coronary revascularization in Washington State: an analysis of the Clinical Outcomes Assessment Program (COAP) registry. J Am Heart Assoc. 2012;1(5):e002733. doi: 10.1161/JAHA.112.002733. Riley RF Don CW Aldea GS Mokadam NA Probstfield J Maynard C Recent trends in adherence to secondary prevention guidelines for patients undergoing coronary revascularization in Washington State: an analysis of the Clinical Outcomes Assessment Program (COAP) registry J Am Heart Assoc 2012 1 5 e002733 10.1161/JAHA.112.002733 10 Milojevic M, Head SJ, Parasca CA, Serruys PW, Mohr FW, Morice MC, et al. Causes of death following PCI versus CABG in complex CAD: 5-year follow-up of SYNTAX. J Am Coll Cardiol. 2016;67(1):42-55. doi: 10.1016/j.jacc.2015.10.043. Milojevic M Head SJ Parasca CA Serruys PW Mohr FW Morice MC Causes of death following PCI versus CABG in complex CAD: 5-year follow-up of SYNTAX J Am Coll Cardiol 2016 67 1 42 55 10.1016/j.jacc.2015.10.043 11 Benedetto U, Caputo M, Vohra H, Bryan A, Angelini GD. State of the art in coronary revascularization: everolimus eluting stents versus multiple arterial grafting. Int J Cardiol. 2016;219:345-9. doi: 10.1016/j.ijcard.2016.06.059. Benedetto U Caputo M Vohra H Bryan A Angelini GD State of the art in coronary revascularization: everolimus eluting stents versus multiple arterial grafting Int J Cardiol 2016 219 345 349 10.1016/j.ijcard.2016.06.059 12 Shah R, Yang Y, Bentley JP, Banahan BF 3(rd). Comparative effectiveness of coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI) in elderly patients with diabetes. Curr Med Res Opin. 2016;32(11):1891-8. doi: 10.1080/03007995.2016.1219708. Shah R Yang Y Bentley JP Banahan 3 BF Comparative effectiveness of coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI) in elderly patients with diabetes Curr Med Res Opin 2016 32 11 1891 1898 10.1080/03007995.2016.1219708 13 Marui A, Kimura T, Nishiwaki N, Mitsudo K, Komiya T, Hanyu M, et al; CREDO-Kyoto PCI/CABG Registry Cohort-2 Investigators. Five-year outcomes of percutaneous versus surgical coronary revascularization in patients with diabetes mellitus (from the CREDO-Kyoto PCI/CABG Registry Cohort-2). Am J Cardiol. 2015;115(8):1063-72. doi: 10.1016/j.amjcard.2015.01.544. Marui A Kimura T Nishiwaki N Mitsudo K Komiya T Hanyu M CREDO-Kyoto PCI/CABG Registry Cohort-2 Investigators Five-year outcomes of percutaneous versus surgical coronary revascularization in patients with diabetes mellitus (from the CREDO-Kyoto PCI/CABG Registry Cohort-2) Am J Cardiol 2015 115 8 1063 1072 10.1016/j.amjcard.2015.01.544 14 Flather M, Rhee JW, Boothroyd DB, Boersma E, Brooks MM, Carrie D, et al. The effect of age on outcomes of coronary artery bypass surgery compared with balloon angioplasty or bare-metal stent implantation among patients with multivessel coronary disease. A collaborative analysis of individual patient data from 10 randomized trials. J Am Coll Cardiol. 2012;60(21):2150-7. doi: 10.1016/j.jacc.2012.08.982. Flather M Rhee JW Boothroyd DB Boersma E Brooks MM Carrie D The effect of age on outcomes of coronary artery bypass surgery compared with balloon angioplasty or bare-metal stent implantation among patients with multivessel coronary disease. A collaborative analysis of individual patient data from 10 randomized trials J Am Coll Cardiol 2012 60 21 2150 2157 10.1016/j.jacc.2012.08.982 15 Krempf M, Simpson RJ Jr, Ramey DR, Brudi P, Giezek H, Tomassini JE, et al. Patient and physician factors influence decision-making in hypercholesterolemia: a questionnaire-based survey. Lipids Health Dis. 2015;14:45. doi: 10.1186/s12944-015-0037-y.. Krempf M Simpson RJ Jr Ramey DR Brudi P Giezek H Tomassini JE Patient and physician factors influence decision-making in hypercholesterolemia: a questionnaire-based survey Lipids Health Dis 2015 14 45 45 10.1186/s12944-015-0037-y. 16 Zhao S, Wang Y, Mu Y, Yu B, Ye P, Yan X, et al; DYSIS-China Study Investigators. Prevalence of dyslipidaemia in patients treated with lipid-lowering agents in China: results of the DYSlipidemia International Study (DYSIS). Atherosclerosis. 2014;235(2):463-9. doi: 10.1016/j.atherosclerosis.2014.05.916. Zhao S Wang Y Mu Y Yu B Ye P Yan X DYSIS-China Study Investigators Prevalence of dyslipidaemia in patients treated with lipid-lowering agents in China: results of the DYSlipidemia International Study (DYSIS) Atherosclerosis 2014 235 2 463 469 10.1016/j.atherosclerosis.2014.05.916 17 Lee VW, Chau RY, Cheung HY, Yu CM, Lam YY, Yan BP. How low should we target the LDL goal to improve survival for acute coronary syndrome patients in Hong Kong? BMC Cardiovasc Disord. 2015;15:117. doi: 10.1186/s12872-015-0117-y. Lee VW Chau RY Cheung HY Yu CM Lam YY Yan BP How low should we target the LDL goal to improve survival for acute coronary syndrome patients in Hong Kong BMC Cardiovasc Disord 2015 15 117 117 10.1186/s12872-015-0117-y 18 Andrikopoulos G, Tzeis S, Nikas N, Richter D, Pipilis A, Gotsis A, et al. Short-term outcome and attainment of secondary prevention goals in patients with acute coronary syndrome--results from the countrywide TARGET study. Int J Cardiol. 2013;168(2):922-7. doi: 10.1016/j.ijcard.2012.10.049. Andrikopoulos G Tzeis S Nikas N Richter D Pipilis A Gotsis A Short-term outcome and attainment of secondary prevention goals in patients with acute coronary syndrome--results from the countrywide TARGET study Int J Cardiol 2013 168 2 922 927 10.1016/j.ijcard.2012.10.049 19 Jin H, Tang C, Wei Q, Chen L, Sun Q, Ma G, et al. Age-related differences in factors associated with the underuse of recommended medications in acute coronary syndrome patients at least one year after hospital discharge. BMC Cardiovasc Disord. 2014;14:127. doi: 10.1186/1471-2261-14-127. Jin H Tang C Wei Q Chen L Sun Q Ma G Age-related differences in factors associated with the underuse of recommended medications in acute coronary syndrome patients at least one year after hospital discharge BMC Cardiovasc Disord 2014 14 127 127 10.1186/1471-2261-14-127 20 Rajendran S, Visvanathan R, Tavella R, Weekes AJ, Morgan C, Beltrame JF. In patients with chronic stable angina, secondary prevention appears better in the very old compared to younger patients: the Coronary Artery Disease in gENeral practiCE (CADENCE) Substudy. Heart Lung Circ. 2013;22(2):116-21. doi: 10.1016/j.hlc.2012.09.003. Rajendran S Visvanathan R Tavella R Weekes AJ Morgan C Beltrame JF In patients with chronic stable angina, secondary prevention appears better in the very old compared to younger patients: the Coronary Artery Disease in gENeral practiCE (CADENCE) Substudy Heart Lung Circ 2013 22 2 116 121 10.1016/j.hlc.2012.09.003 21 Hogh A, Lindholt JS, Nielsen H, Jensen LP, Johnsen SP. Age- and gender-related differences in the use of secondary medical prevention after primary vascular surgery: a nationwide follow-up study. Eur J Vasc Endovasc Surg. 2012;43(3):300-7. doi: 10.1016/j.ejvs.2011.12.003. Hogh A Lindholt JS Nielsen H Jensen LP Johnsen SP Age- and gender-related differences in the use of secondary medical prevention after primary vascular surgery: a nationwide follow-up study Eur J Vasc Endovasc Surg 2012 43 3 300 307 10.1016/j.ejvs.2011.12.003 22 Victor BM, Teal V, Ahedor L, Karalis DG. Gender differences in achieving optimal lipid goals in patients with coronary artery disease. Am J Cardiol. 2014;113(10):1611-5. doi: 10.1016/j.amjcard.2014.02.018. Victor BM Teal V Ahedor L Karalis DG Gender differences in achieving optimal lipid goals in patients with coronary artery disease Am J Cardiol 2014 113 10 1611 1615 10.1016/j.amjcard.2014.02.018 23 Jankowski P, Czarnecka D, Wolfshaut-Wolak R, Lysek R, Lukaszewska A, Surowiec S, et al. Age, sex, and secondary prevention of ischaemic heart disease in everyday practice. Kardiol Pol. 2013;71(12):1251-9. doi: 10.5603/KP.a2013.0148. Jankowski P Czarnecka D Wolfshaut-Wolak R Lysek R Lukaszewska A Surowiec S Age, sex, and secondary prevention of ischaemic heart disease in everyday practice Kardiol Pol 2013 71 12 1251 1259 10.5603/KP.a2013.0148 Artigos Originais Comparação de Prevenção Secundária em Intervenção Coronária Percutânea e Cirurgia de Revascularização Miocárdica Gao Xia-qing 1 2 LI Yanfang 1 2 Jiang Zhi-li 1 2 Beijing Anzhen Hospital - Capital Medical University Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing - China Correspondência: Yanfang LI Beijing Anzhen Hospital of Capital Medical University, Anzhen Street. 100029, Beijing - China. E-mail: 422655835@qq.com

Contribuição dos autores

Concepção e desenho da pesquisa e Obtenção de dados: Xia-qing Gao, Yan-fang Li, Zhi-li Jiang; Análise e interpretação dos dados e Redação do manuscrito: Xia-qing Gao; Análise estatística: Xia-qing Gao, Zhi-li Jiang; Obtenção de financiamento e Revisão crítica do manuscrito quanto ao conteúdo intelectual importante: Yan-fang Li.

Potencial conflito de interesses

Declaro não haver conflito de interesses pertinentes.

 Resumo Fundamento:

Há poucos dados referentes às disparidades no manejo de fatores de risco cardiovascular entre pacientes tratados com intervenção coronária percutânea (ICP) e aqueles tratados com cirurgia de revascularização miocárdica (CRM).

 Objetivo:

Avaliar se as taxas de cumprimento de metas de fatores de risco cardiovascular diferiram entre pacientes submetidos a ICP ou a CRM.

 Métodos:

Revisão retrospectiva de banco de dados de prontuários médicos de pacientes admitidos no Hospital Beijing Anzhen entre 1 de janeiro de 2014 e 31 de dezembro de 2014, submetidos a ICP ou a CRM.

 Resultados:

Comparado ao grupo CRM, o grupo ICP apresentou taxas significativamente maiores de cumprimento de meta de colesterol da lipoproteína de baixa densidade (LDL-C) < 1,8 mmol/L (28,6% vs. 24,7%; p < 0,01), LDL-C < 2,07 mmol/L (43,5% vs. 39,4%; p < 0,01) e pressão arterial (PA) <140/90 mmHg (85,6% vs. 77,7%; p < 0,01). Comparados aos pacientes ≥ 60 anos de idade, aqueles < 60 anos de idade apresentaram melhor taxa de cumprimento de meta de PA < 140/90 mmHg (87,7% vs. 84,4%; p < 0,01) no grupo ICP, e melhores taxas de cumprimento de meta de glicemia de jejum (GJ) < 7 mmol/L (79.4% vs.72.0%; p < 0.01) e HbA1c < 7% (79.4% vs. 70.1%; p < 0.01) no grupo CRM. Comparados às mulheres, os homens apresentaram melhores taxas de cumprimento de meta de LDL-C < 2,07 mmol/L (24,7% vs. 28,5%; p < 0,01), GJ < 7 mmol/L (71,8% vs. 75,2%; p < 0,01) e HbA1c < 7% (70,4% vs. 74,1%; p < 0,01) no grupo ICP.

 Conclusão:

Em geral, o grupo ICP apresentou maior probabilidade do que o grupo CRM de cumprir as metas de LDL-C < 1,8 mmol/L e PA. O controle dos fatores de risco cardiovascular diferiu entre pacientes ≥ 60 e < 60 anos de idade. As mulheres apresentaram menor probabilidade de cumprir as metas de LDL-C, GJ e HbA1c.

 Palavras-chave Intervenção Coronária Percutânea Ponte de Artéria Coronária Revascularização do Miocárdio Fatores de Risco National Nature Science Foundaction of China 81270380 O presente estudo foi financiado pelo National Nature Science Foundaction of China (Nº. 81270380). Introdução

Na China, o número de pacientes submetidos a revascularização miocárdica cresce com o aumento das doenças cardiovasculares. A intervenção coronária percutânea (ICP) e a cirurgia de revascularização miocárdica (CRM) são os dois principais procedimentos de revascularização miocárdica. Ainda que a ICP e a CRM salvem muitas vidas, não evitam a progressão da aterosclerose arterial, permanecendo altas as taxas de eventos maiores e de revascularização secundária após 5 anos.1 O uso de medicamento secundário preventivo é importante para esses pacientes.2,3

Cerca de 14.000 pacientes são submetidos anualmente a CRM ou ICP no Hospital Beijing Anzhen. Na prática, no entanto, descobrimos que cardiologistas e cirurgiões cardíacos têm preocupações diferentes quanto ao prognóstico de longo prazo. Isso deve influenciar a prescrição de medicamentos de prevenção secundária, levando a um desequilíbrio no controle dos fatores de risco relacionados à doença arterial coronária (DAC), como colesterol da lipoproteína de baixa densidade (LDL-C), pressão arterial (PA), glicemia de jejum (GJ) e hemoglobina glicada A1c (HbA1c), em pacientes submetidos a ICP ou CRM. Além disso, estudos relataram que o controle dos fatores de risco cardiovascular diferiu em diferentes faixas etárias e conforme o sexo. Levantamos a hipótese de que pacientes submetidos a CRM, em comparação àqueles submetidos a ICP, teriam menor probabilidade de atingir as metas de lipídeos, GJ, HbA1c e PA. Avaliamos o cumprimento das metas e desfecho clínico de pacientes submetidos a ICP ou CRM, assim como as taxas de cumprimento de meta em pacientes ≥ 60 anos de idade e ≥ 60 anos de idade, e em mulheres e homens.

 Métodos População do estudo

Este estudo retrospectivo arrolou 14.230 pacientes submetidos a ICP (n = 9.866) ou CRM (n = 4.364) no Hospital Beijing Anzhen entre 1 de janeiro de 2014 e 31 de dezembro de 2014. A data-índice foi a do procedimento de revascularização. Foram excluídos 7.707 pacientes pelos seguintes motivos: idade < 18 anos com história de revascularização miocárdica, tumor maligno, síndrome de disfunção de múltiplos órgãos, ou transplante de órgão, dados demográficos incompletos, ausência de registro de prescrição de medicamento contínuo, indisponibilidade da segunda medida de nível lipídico após a data-índice. Portanto, este estudo incluiu 6.523 pacientes na análise, pareados conforme escore de propensão.

 Coleta de dados

Os dados clínicos foram recuperados de prontuários médicos eletrônicos, sendo que os dados clínicos relevantes foram extraídos até 31 de dezembro de 2015, o início do período de coleta de dados. Os seguintes dados foram obtidos: idade; sexo; história da enfermidade atual; comorbidades (hipertensão, diabetes, acidente vascular encefálico, doença vascular periférica, doença renal crônica); fatores de risco cardiovascular (tabagismo, consumo de álcool, obesidade); lesões das artérias coronárias (SYNTAX Score); níveis de lipídeos, PA, GJ e HbA1c anteriores à alta e durante o seguimento. Dados sobre morte cardíaca, síndrome coronária aguda (SCA) recorrente, acidente vascular encefálico, infarto agudo do miocárdio (IAM) não fatal, e revascularização foram também coletados para a análise de desfecho. Os desfechos compostos foram definidos como morte cardíaca, SCA recorrente e acidente vascular encefálico. Definiu-se SCA recorrente como IAM recorrente não fatal e angina instável. Os níveis de lipídeos, PA, GJ e HbA1c anteriores à alta foram definidos como aqueles anteriores ao procedimento de revascularização miocárdica, enquanto os níveis de lipídeos, PA, GJ e HbA1c do seguimento foram definidos como aqueles mais recentes (pelo menos 3 meses após a alta) caso não houvesse qualquer evento de desfecho, ou os níveis de lipídeos, PA, GJ e HbA1c da nova hospitalização caso houvesse um evento de desfecho. Hipertensão, diabetes, dislipidemia, acidente vascular encefálico, doença vascular periférica, doença renal crônica, abuso de álcool e obesidade foram definidos em publicação anterior.4 O período de seguimento de cada indivíduo desde a data da alta até 31 de dezembro de 2015 foi calculado. O cumprimento de meta de lipídeos foi definido como LDL-C < 1,8 mmol/L (70 mg/dL) e colesterol da não lipoproteína de alta densidade (não HDL-C) < 2,6 mmol/L (100 mg/dL),5 ou LDL-C < 2,07 mmol/L (80 mg/dL) e não HDL-C < 2,8 mmol/L (110 mg/dL).6 O cumprimento de meta de GJ foi definido como GJ < 7,0 mmol/L, sendo o de HbA1c < 7%. O cumprimento de meta de PA foi definido como PA < 140/90 mmHg.7

Este estudo foi aprovado pelo Comitê de Ética do Hospital Beijing Anzhen.

 Métodos estatísticos

Os escores de propensão foram estimados usando análise de regressão logística múltipla. Os pacientes submetidos a ICP ou CRM foram pareados 1:1 usando-se o método de pareamento por vizinho mais próximo.

As variáveis contínuas com distribuição normal foram apresentadas como média ± desvio-padrão, e aquelas com distribuição não normal, como mediana e intervalo interquartil. As variáveis categóricas foram apresentadas como números absolutos e porcentagens. O teste K-S foi usado para verificar a normalidade dos dados. As variáveis contínuas foram comparadas usando-se o teste de postos sinalizados de Wilcoxon ou teste t pareado. As variáveis categóricas foram comparadas usando-se o teste do qui-quadrado. Curvas de sobrevida de Kaplan-Meier foram usadas para comparar a incidência acumulada de eventos de desfecho composto. Realizou-se análise de regressão de Cox para avaliar a influência de covariáveis basais nos desfechos compostos. O teste log-rank foi realizado antes da regressão de Cox. Variáveis com valores de P ≤ 0,10 foram candidatas ao modelo multivariado. As covariáveis incluídas na análise de regressão de Cox foram: idade, sexo, hipertensão, diabetes mellitus, dislipidemia, tabagismo, acidente vascular encefálico, doença arterial periférica, doença renal crônica, índice de massa corporal (IMC), fração de ejeção (FE) ventricular esquerda, SYNTAX Score, e cumprimento de meta de LDL-C, GJ, PA e HbA1c. Todas as análises foram realizadas com SPSS, versão 22.0 (IBM, Armonk, NY, EUA). Todos os testes foram bicaudais, sendo os valores de P < 0,05 considerados estatisticamente significativos.

 Resultados Características basais

Um total de 6.523 (ICP = 4.728; CRM = 1.795) pacientes foram avaliados no estudo. Em comparação aos pacientes no grupo ICP, os do grupo CRM eram mais idosos, tinham maior probabilidade de apresentar história de diabetes e acidente vascular encefálico, menor probabilidade de história de hipertensão e dislipidemia, apresentavam níveis mais baixos de IMC, HDL-C e FE ventricular esquerda, e tinham maior SYNTAX Score. Criou-se um total de 1.790 pares de pacientes após pareamento por escore de propensão para toda a população. As características basais não diferiram significativamente entre os grupos ICP e CRM após pareamento por escore de propensão (Tabela 1).

Características basais dos pacientes nos grupos de intervenção coronária percutânea (ICP) e cirurgia de revascularização miocárdica (CRM)
População total População pareada por propensão
ICP n = 4728 CRM n = 1795 Valor de p ICP n = 1790 CRM n = 1790 Valor de p
Idade (anos) 58,9 ± 10,2 61,9 ± 9,0 < 0,01 62,0 ± 9,9 61,9 ± 9,0 0,68
Sexo (masculino) 3499(74,0) 1353(75,4) 0,26 1369(76,5) 1349(75,4) 0,43
Hipertensão 2394(61,2) 1073(59,8) < 0,01 1068(59,6) 1072(59,9) 0,87
Diabetes 1461(30,9) 634(35,3) 0,001 632(35,3) 630(35,5) 0,94
Dislipidemia 3749(79,3) 1361(75,8) 0,002 1360(76,0) 1348(75,3) 0,64
AVE 265(5,6) 169(9,4) < 0,01 150(8,4) 168(9,4) 0,29
DVP 52(1,1) 23(1,3) 0,54 27(1,5) 23(1,3) 0,57
DRC 33(0,7) 9(0,5) 0,38 7(0,4) 9(0,5) 0,62
Tabagismo 2392(50,6) 863(48,1) 0,07 848(47,4) 863(48,2) 0,62
IMC 26,5 ± 3,4 25,4 ± 2,9 < 0,01 25,3 ± 3,3 25,4 ± 2,9 0,57
FEVE (%) 62,2 ± 8,3 60,4 ± 9,0 < 0,01 60,7 ± 9,1 60,5 ± 9,0 0,50
SYNTAX Score 23,4 ± 9,3 28,1 ± 10,1 < 0,01 27,8 ± 9,3 28,0 ± 10,2 0,19
Níveis de lipídeos antes da alta (mmol/L)
CT 4,58 ± 0,9 4,57 ± 1,1 0,87 4,56 ± 1,0 4,57 ± 1,1 0,82
TG 1,87 ± 1,2 1,83 ± 1,1 0,24 1,83 ± 1,1 1,83 ± 1,1 0,99
LDL-C 2,86 ± 0,8 2,88 ± 0,9 0,52 2,87 ± 0,8 2,88 ± 0,9 0,75
HDL-C 1,00 ± 0,2 0,97 ± 0,2 < 0,01 0,97 ± 0,2 0,97 ± 0,2 0,56
Níveis de GJ (mmol/L) e HbA1c (%) antes da alta
GJ 6,08 ± 1,7 5,77 ± 1,5 0,07 5,91 ± 1,6 5,77 ± 1,5 0,36
HbA1c 5,93 ± 1,1 5,78 ± 1,1 0,17 5,80 ± 1,1 5,78 ± 1,1 0,64
Pressão arterial (mmHg) antes da alta
PAS 127,65 ± 15,4 124,04 ± 17,7 0,13 124,5 ± 16,3 124,04 ± 17,7 0,91
PAD 76,54 ± 11,3 75,35 ± 10,6 0,04 75,04 ± 10,3 75,35 ± 10,6 0,32

Valores apresentados como média ± desvio-padrão e mediana com intervalo interquartil ou n (%); AVE: acidente vascular encefálico; DVP: doença vascular periférica; DRC: doença renal crônica; IMC: índice de massa corporal; FEVE: fração de ejeção ventricular esquerda; CT: colesterol total; TG: triglicerídeos; LDL-C: colesterol da lipoproteína de baixa densidade; HDL-C: colesterol da lipoproteína de alta densidade; GJ: glicemia de jejum; HbA1c: hemoglobina A1c; PAS: pressão arterial sistólica; PAD: pressão arterial diastólica.

 Taxas de cumprimento de meta de LDL-C, GJ, HbA1c e PA no total e no pareamento por escore de propensão de pacientes dos grupos ICP e CRM

Em comparação aos pacientes no grupo CRM, as taxas de cumprimento de meta de LDL-C < 1,8 mmol/L, LDL-C < 2,07 mmol/L e PA < 140/90 mmHg no grupo ICP foram significativamente maiores nos pacientes não pareados após a alta. As taxas de cumprimento de meta de GJ e HbA1C não diferiram significativamente entre os dois grupos após a alta (Tabela 2). Nos pacientes pareados por propensão, as taxas de cumprimento de meta de LDL-C < 1,8 mmol/L, LDL-C < 2,07 mmol/L e PA < 140/90 mmHg no grupo ICP foram significativamente maiores do que no grupo CRM. As taxas de cumprimento de meta de GJ e HbA1c não HbA1c diferiram significativamente entre os dois grupos (Tabela 2).

Taxas de cumprimento de metas de LDL-c, GJ, HbA1c e PA nos grupos de intervenção coronária percutânea (ICP) e cirurgia de revascularização miocárdica (CRM)
População total População pareada por propensão
Metas dos fatores de risco ICP CRM p ICP CRM p
LDL-c < 1,8 mmol/La 1352(28,6) 443(24,7) 0,002 522(29,2) 442(24,7) 0,003
LDL-c < 2,07 mmol/Lb 2055(43,5) 708(39,4) 0,003 787(44,0) 707(39,5) 0,007
GJ < 7 mmol/Lc 3498(74,2) 1342(74,8) 0,492 1361(76,0) 1342 (75,0) 0,46
HbA1c < 7%c 3456(73,1) 1321(73,6) 0,686 1349(75,4) 1319(73,7) 0,25
PA < 140/80 mmHgd 4049(85,6) 1394(77,7) 0,000 1525(85,2) 1391(77,7) 0,000

Valores apresentados como n (%); LDL-C: colesterol da lipoproteína de baixa densidade; GJ: glicemia de jejum; HbA1c: hemoglobina A1c; PA: pressão arterial.

Diretriz chinesa de prevenção e tratamento de dislipidemia em adultos, 2007;

Diretriz de ESC/EAS para manejo de dislipidemias, 2011;

Diretriz chinesa de prevenção e tratamento de diabetes tipo 2, 2013;

Diretriz chinesa de prevenção e tratamento de hipertensão, 2011.

 Desfechos clínicos

Em pacientes não pareados, as taxas de desfecho composto foram significativamente maiores no grupo ICP do que no grupo CRM (Tabela 4). A mediana da duração do seguimento foi de 10,99 meses. Nos pacientes pareados por propensão, as taxas de desfecho composto não diferiram significativamente entre os dois grupos (Figura 1, Tabela 4). As taxas de SCA recorrente foram significativamente maiores no grupo ICP do que no grupo CRM tanto nos pacientes pareados quanto naqueles não pareados (Tabela 4). A incidência de acidente vascular encefálico foi significativamente maior no grupo CRM do que no grupo ICP (Tabela 4). Na análise de regressão de Cox multivariada, LDL-C < 1,8 mmol/L e HbA1c < 7% foram preditores independentes de desfechos compostos no total de pacientes não pareados, nos grupos ICP e CRM, sendo as razões de risco menores naqueles pacientes que cumpriram as metas (Tabela 3). Para determinar se as taxas de desfecho composto nos pacientes pareados de acordo com os grupos ICP e CRM eram consistentes, aplicamos análise de subgrupo. Comparados aos pacientes do grupo ICP, os do grupo CRM apresentaram melhor desfecho clínico nos subgrupos diabetes, obesidade e pacientes ≥ 60 anos de idade (Figura 2).

Preditores independentes de desfecho composto nos grupos de intervenção coronária percutânea (ICP) e cirurgia de revascularização miocárdica (CRM)
Geral ICP CRM
Variáveis HR IC95% p HR IC95% p HR IC95% p
Sexoa 0,298 (1,08-1,68) 0,008 0,251 (1,01-1,64) 0,043 0,414 (0,87-2,64) 0,144
ICP vs CRM 0,821 (1,81-2,85) 0,000
Tabagismoa 1,692 (1,29-2,72) 0,000 1,783 (1,43-3,13) 0,000 1,113 (0,98-1,81) 0,754
LDL-c < 1.8 -2,197 (0,07-0,17) 0,000 -2,329 (0,06-0,16) 0,000 -1,023 (0,09-0,45) 0,000
HbA1c < 7% -0,363 (0,58-0,85) 0,000 -0,403 (0,54-0,82) 0,000 -0,392 (0,53-0,88) 0,000
FE < 40%b -0,241 (0,52-1,19) 0,252 -0,101 (0,56-1,47) 0,686 -0,825 (0,20-0,95) 0,037
Dislipidemiac 1,164 (0,96-1,45) 0,120 1,256 (1,03-1,63) 0,030 1,09 (0,59-1,43) 0,679
PA < 140/80 mmHg -0,475 (0,32-0,49) 0,000 -0,432 (0,37-0,50) 0,000 -0,129 (0,39-1,76) 0,788

Valores apresentados como n (%); IC: intervalo de confiança; HR: razão de risco;

sexo e tabagismo foram preditores significativos no geral e no grupo ICP;

FE (fração de ejeção) > 40% foi preditor significativo no grupo CRM;

dislipidemia foi preditor significativo no grupo ICP.

 Desfechos clínicos nos grupos de intervenção coronária percutânea (ICP) e cirurgia de revascularização miocárdica (CRM)
População total População pareada por propensão
ICP CRM HR (IC95%) p ICP CRM HR (IC95%) p
Desfechos compostos 424(9,0) 101(5,6) 1,652(1,32,2,07) 0,000 126(7,0) 101(5,6) 1,27 (0,97,1,66) 0,09
SCA recorrente 389(8,2) 80(4,5) 5,935(4,619,7,626) 0,000 116(6,5) 80(4,5) 1,48(1,11,1,99) < 0,01
Acidente vascular encefálico 29(0,6) 19(1,1) 1,535(0,858,2,748) 0,146 8(6,4) 19(1,1) 0,42(0,18,0,96) 0,03
Morte cardíaca 6(0,1) 2(0,1) 3,007(0,606,14,917) 0,157 2(0,1) 2(0,1) 1,00(0,14,7,11) 1,00

Valores apresentados como n (%). Os desfechos compostos incluíram síndrome coronária aguda (SCA) recorrente, acidente vascular encefálico e morte cardíaca. HR: razão de risco; IC: intervalo de confiança.

Curva de Kaplan-Meier: eventos acumulados de desfecho composto. A taxa de eventos de desfecho composto (morte cardíaca/síndrome coronária aguda recorrente/acidente vascular encefálico) não diferiu significativamente entre os pacientes submetidos a intervenção coronária percutânea (ICP) ou cirurgia de revascularização miocárdica (CRM).

Comparação das razões de risco não ajustadas de síndrome coronária aguda recorrente para subgrupos em pacientes pareados por propensão dos grupos de intervenção coronária percutânea (ICP) e cirurgia de revascularização miocárdica (CRM). IC: intervalo de confiança; IMC: índice de massa corporal.

Taxas de cumprimento de meta de LDL-C, GJ, HbA1c e PA nos pacientes não pareados conforme as faixas etárias

Nos pacientes não pareados em geral e no grupo ICP, em comparação aos pacientes ≥ 60 anos de idade, os pacientes < 60 anos de idade apresentaram melhores taxas de cumprimento de meta de PA < 140/90 mmHg e piores taxas de cumprimento de meta de LDL-C < 2,07 mmol/L. As taxas de cumprimento de meta de LDL-C < 1,8 mmol/L, GJ < 7 mmol/L e HbA1c < 7% não diferiram significativamente. Nos pacientes não pareados do grupo CRM, em comparação àqueles ≥ 60 anos de idade, os pacientes < 60 anos de idade apresentaram melhores taxas de cumprimento de meta de GJ < 7 mmol/L, HbA1c < 7% e PA < 140/90 mmHg; as taxas de cumprimento de meta de LDL-C < 1,8 mmol/L e LDL-C < 2,07 mmol/L não diferiram significativamente entre os dois grupos (Tabela 5).

Taxas de cumprimento de metas de LDL-c, GJ, HbA1c e PA conforme a faixa etária (< 60 anos e ≥ 60 anos) e o sexo
Geral ICP CRM
Taxas de cumprimento de metas de LDL-c, GJ, HbA1c e PA por faixa
Metas dos fatores de risco < 60 ≥ 60 p < 60 ≥ 60 p < 60 ≥ 60 p
LDL-c < 1,8 mmol/La 640(26,3) 1155(28,3) 0,079 474(27,0) 878(29,6)†† 0,056 166(24,4) 277(24,8) 0,859
LDL-c < 2,07 mmol/Lb 967(39,7) 1796(44,0) 0,001 703(40,0) 1352(45,5)†† 0,001 264(38,9) 444(39,8) 0,704
GJ < 7 mmol/Lc 1817(74,5) 3023(74,0) 0,608 1278(72,8) 2219(74,7) 0,138 539(79,4)‡‡ 804(72,0) 0,001
HbA1c < 7%c 1805(72,9) 2972(72,7) 0,240 1266(72,0) 2190(73,7)† 0,196 539(79,4)‡‡ 782(70,1) 0,001
PA < 140/80 mmHgd 2093(85,9) 3350(82,0) 0,000 1541(87,7)* 2508(84,4)†† 0,002 552(81,3) 842(75,4) 0,004
Taxas de cumprimento de metas de LDL-c, GJ, HbA1c e PA conforme o sexo
Metas dos fatores de risco Feminino Masculino p Feminino Masculino p Feminino Masculino p
LDL-c < 1,8 mmol/La 399(24,7) 1396(28,5) 0,003 306(25,5) 1046(29,6) 0,006 93(22,2) 350(25,4) 0,188
LDL-c < 2,07 mmol/Lb 661(40,9) 2102(42,8) 0,165 502(41,9) 1553(44,0) 0,197 159(38,0) 549(39,9) 0,502
GJ < 7 mmol/Lc 1152(71,8) 3689(75,2) 0,002 851(71,0) 2647(75,0) 0,006 301(72,0) 1042(75,7) 0,131
HbA1c < 7%c 1139(70,4) 3638(74,1) 0,003 832(69,4) 2624(74,4) 0,001 307(73,4) 1014(73,6) 0,937
PA < 140/80 mmHgd 1330(82,3) 4113(83,8) 0,137 1019(85,0) 3030(85,9) 0,457 311(74,4) 1083(78,6) 0,068

Valores apresentados como n (%); LDL-C: colesterol da lipoproteína de baixa densidade; GJ: glicemia de jejum; HbA1c: hemoglobina A1c; PA: pressão arterial.

Diretriz chinesa de prevenção e tratamento de dislipidemia em adultos, 2007;

Diretriz de ESC/EAS para manejo de dislipidemias, 2011;

Diretriz chinesa de prevenção e tratamento de diabetes tipo 2, 2013;

Diretriz chinesa de prevenção e tratamento de hipertensão, 2011;

pacientes < 60, comparados no grupo CRM, p < 0,01;

pacientes ≥ 60, comparados no grupo CRM, p < 0,01;

pacientes ≥ 60, comparados no grupo CRM, p < 0,05;

pacientes < 60, comparados no grupo ICP, p < 0,01.

 Taxas de cumprimento de meta de LDL-C, GJ, HbA1c e PA nos pacientes não pareados conforme o sexo

Nos pacientes não pareados em geral e no grupo ICP, em comparação às mulheres, os homens apresentaram melhores taxas de cumprimento de meta de LDL-C < 1,8 mmol/L, GJ < 7 mmol/L e HbA1c < 7%. As taxas de cumprimento de meta de LDL-C < 2,07 mmol/L e PA < 140/90 mmHg não diferiram significativamente. No grupo CRM, essas taxas de cumprimento de meta não diferiram significativamente entre mulheres e homens (Tabela 5).

 Taxas de cumprimento de meta de LDL-C, GJ, HbA1c e PA em pacientes não pareados conforme as faixas etárias e o sexo

Nos pacientes não pareados ≥ 60 anos de idade, em comparação às mulheres, os homens apresentaram melhores taxas de cumprimento de metas de LDL-C < 1,8 mmol/L, GJ < 7 mmol/L e HbA1c < 7%. As taxas de cumprimento de meta de LDL-C < 2,07 mmol/L e PA < 140/90 mmHg não diferiram significativamente. Nos pacientes < 60 anos de idade, essas taxas de cumprimento de meta não diferiram significativamente entre mulheres e homens (Tabela 6).

Taxas de cumprimento de metas de LDL-c, GJ, HbA1c e PA conforme o sexo em pacientes < 60 anos e pacientes ≥ 60 anos de idade
Metas dos fatores de risco < 60 ≥ 60
Feminino Masculino p Feminino Masculino p
LDL-c < 1,8 mmol/La 81(24,5) 559(26,5) 0,426 318(24,7) 837(29,9) 0,001
LDL-c < 2,07 mmol/Lb 120(36,3) 847(40,2) 0,171 541(42,1) 1255(44,8) 0,100
GJ < 7 mmol/Lc 239(72,2) 1578(74,9) 0,290 913(71,0) 2111(75,4) 0,003
HbA1c < 7%c 232(70,1) 1573(74,7) 0,076 907(70,5) 2065(73,8) 0,032
PA < 140/80 mmHgd 277(83,7) 1816(86,2) 0,217 1053(81,9) 2297(82,0) 0,905

Valores apresentados como n (%). LDL-C: colesterol da lipoproteína de baixa densidade; GJ: glicemia de jejum; HbA1c: hemoglobina A1c; PA: pressão arterial.

 Discussão

As técnicas de ICP e CRM foram desenvolvidas rapidamente no final da década de 1990 na China. O volume de ICP aumentou 30%-50% por ano, atingindo 567583 em 2015, na vanguarda mundial. Com o aprimoramento das técnicas cirúrgicas, houve uma grande redução na mortalidade em CRM, tornando-a aceitável por um número crescente de pacientes. Embora a ICP e a CRM tenham salvado muitas vidas, persiste o problema de como reduzir a incidência de revascularização. Portanto, é de particular relevância que se enfatize a prevenção secundária após ICP e CRM.

No presente estudo, nossos principais achados foram: (a) nos pacientes em geral e naqueles pareados por escore de propensão, as taxas de cumprimento de meta de lipídeos e PA diferiram entre os grupos ICP e CRM; entretanto, as taxas de cumprimento de meta de LDL-C, GJ, HbA1c e PA não foram otimistas em nenhum dos grupos; (b) as taxas de cumprimento de meta de LDL-C e PA no grupo ICP e as taxas de cumprimento de meta de GJ e HbA1c no grupo CRM diferiram entre pacientes < 60 anos de idade e aqueles ≥ 60 anos de idade; (c) as taxas de cumprimento de meta de LDL-C, GJ e HbA1c foram significativamente menores nas mulheres no grupo ICP, assim como nos pacientes ≥ 60 anos de idade.

As taxas de cumprimento de meta de LDL-C e PA no grupo ICP foram significativamente maiores do que as do grupo CRM, sendo uma possível explicação a diferença no uso da medicação e na adesão à mesma. Hlatky et. al observaram que as taxas de medicação de prevenção secundária foram significativamente menores nos pacientes do grupo CRM do que naqueles do grupo ICP, sendo o uso de estatinas significativamente menor nos pacientes do grupo CRM do que naqueles do grupo ICP.8 Entre as possíveis razões para tais disparidades, destacam-se: (a) no nosso hospital, após CRM, alguns pacientes foram cuidados por cirurgiões, e as estratégias de tratamento diferem entre cardiologistas e cirurgiões cardíacos. Os cardiologistas seguem diretrizes e têm melhor desempenho no uso de medicamentos preventivos do que os cirurgiões cardíacos, que, em geral, prestam mais atenção no sucesso da cirurgia, nas complicações pós-operatórias e na cicatrização da ferida do que na prescrição de medicamentos de prevenção secundária e educação para a saúde antes da alta;4 (b) alguns pacientes podem ter sido acompanhados por cardiologista após a CRM no ambulatório; entretanto, os cardiologistas podem ter sido treinados para considerar a CRM como um tratamento mais efetivo ou completo, levando a negligenciarem a prevenção secundária de longo prazo; e (c) os pacientes podem considerar que a CRM seja um tratamento definitivo para a DAC e que os medicamentos não sejam mais necessários, o que pode reduzir suas visitas médicas ambulatoriais, nas quais teriam oportunidade de obter orientações úteis.9 As taxas de cumprimento de meta de GJ e HbA1c foram baixas e não diferiram significativamente entre os grupos ICP e CRM. Apenas menos de um terço de todos os pacientes diabéticos atingiram suas metas de GJ e HbA1c. Os hipoglicemiantes não fazem parte do tratamento medicamentoso otimizado, que, não raro, é o único considerado por cardiologistas, que acabam por ignorar o controle da GJ. Outra razão poderia ser que, ainda que os pacientes diabéticos sejam orientados pelo cardiologista e cirurgião cardíaco a procurar um ambulatório de endocrinologia, menos frequentemente o fazem, por já frequentarem um ambulatório.

A despeito das disparidades entre os pacientes dos grupos ICP e CRM quanto ao controle dos fatores de risco cardiovascular, as taxas de cumprimento de metas de LDL-C, GJ, HbA1c e PA permanecem baixas no grupo ICP, possivelmente porque cardiologistas intervencionistas estão em geral mais condicionados a considerar a terapia antiplaquetária dupla e ignorar o uso de outros medicamentos de prevenção secundária.

No nosso estudo, considerando-se os pacientes não pareados, houve um número significativamente maior de desfechos compostos no grupo ICP do que no grupo CRM. Esse achado foi consistente com o de estudos prévios, que sugerem melhores desfechos clínicos entre pacientes submetidos a CRM do que entre aqueles submetidos a ICP.10,11 Considerando-se os pacientes pareados por propensão, embora a taxa de SCA recorrente tenha sido significativamente maior no grupo ICP, os desfechos compostos não diferiram significativamente entre os dois grupos. Na nossa análise de regressão de Cox multivariada, sexo, tabagismo e cumprimento de metas de LDL-c, HbA1c e PA foram preditores independentes para desfechos compostos no grupo ICP, enquanto FE > 40% e cumprimento de metas de LDL-c e PA foram preditores independentes para desfechos compostos no grupo CRM. As taxas de cumprimento de meta de LDL-c e PA foram significativamente maiores no grupo ICP; a taxa de cumprimento de meta de HbA1c, embora não significativamente diferente, foi melhor no grupo ICP pareado por propensão. Os resultados sugerem que prevenção secundária foi importante para reduzir eventos após a revascularização. Na análise de subgrupo pareada por propensão, os pacientes com diabetes, obesidade e ≥ 60 anos de idade tiveram melhor desfecho clínico no grupo CRM, em concordância com estudos anteriores.12-14

A taxa de cumprimento de meta de LDL-C < 2,07 mmol/L de pacientes com SCA no estudo DYSIS-China foi de 29,7%. No nosso estudo, ainda que significativamente melhor, essa taxa permaneceu muito baixa nos grupos ICP e CRM. Estudos anteriores relataram, em pacientes com SCA, níveis basais de LDL-C mais baixos em chineses do que em ocidentais.15,16 A diretriz chinesa de manejo de lipídeos recomenda nível de LDL-C inferior a 2,07 mmol/L. Há controvérsia se a meta de LDL-C deve concordar com aquela das diretrizes de manejo de lipídeos dos países ocidentais (LDL-C < 1,8 mmol/L). Lee et al. observaram que, em comparação com o nível de LDL-C < 2,6 mmol/L, o nível de LDL-C < 1,8 mmol/L não melhorou a sobrevida de pacientes com SCA.17 Entretanto, no nosso estudo, o cumprimento de meta de LDL-C < 1,8 mmol/L foi um preditor independente de diminuição do risco de desfecho composto,18 sugerindo que, no futuro, a meta de LDL-C da diretriz chinesa de manejo de lipídeos seja consistente com aquela dos países ocidentais.

No grupo ICP, a taxa de cumprimento de meta de PA foi maior nos pacientes < 60 anos de idade do que naqueles ≥ 60 anos de idade, enquanto as taxas de cumprimento de meta de GJ e HbA1c foram maiores nos pacientes < 60 anos de idade no grupo CRM. Em concordância com estudos prévios, esses resultados indicam que pacientes mais idosos sempre subutilizam os medicamentos de prevenção secundária recomendados, tendo baixa adesão ao tratamento com os mesmos,19 o que leva a pior cumprimento de meta de fator de risco. Entretanto, o cumprimento de meta de LDL-C foi bem melhor nos pacientes ≥ 60 anos de idade. Esse resultado diferiu daqueles da maioria dos estudos anteriores, mas foi consistente com o de Rajendran et al.,20 que relataram maior frequência de cumprimento de meta de lipídeos entre pacientes mais idosos do que entre os mais jovens. Esses resultados podem sugerir que os clínicos no nosso hospital estejam percebendo cada vez mais a importância do tratamento com estatina. Hogh et al.,21 descobriram que as diferenças relativas a idade no uso de medicamentos de prevenção secundária foram reduzidas ou até eliminadas, sugerindo que as disparidades no cumprimento de meta de fator de risco serão eliminadas com o tempo. O motivo da inconsistência quanto ao cumprimento de meta de fator de risco entre os grupos ICP e CRM em diferentes grupos etários permanece pouco claro, mas os resultados sugerem que devemos dar mais atenção aos pacientes mais idosos na prevenção secundária.

Considerou-se que mulheres tinham menor probabilidade de cumprir suas metas de fator de risco cardiovascular, pois têm menor probabilidade de tomar os medicamentos de prevenção secundária por razões diversas. Por exemplo, os níveis decrescentes de estrogênio, maior número de eventos adversos e pobre adesão devem influenciar o uso de medicamentos.22 Entretanto, em seu estudo, Jankowski et al.,23 descobriram que a frequência de cumprimento das metas recomendadas na prevenção secundária não se relacionou ao sexo dos pacientes. No nosso estudo, as taxas de cumprimento de meta de LDL-C, GJ e HbA1c foram significativamente maiores entre os homens do que entre as mulheres no grupo ICP e em pacientes ≥ 60 anos de idade. Esse resultado sugere que devamos prestar atenção às mulheres mais idosas durante o processo de prevenção secundária, garantindo que recebam o tratamento otimizado.

Limitações do estudo

Nosso estudo apresenta várias limitações. Teve um desenho observacional monocêntrico e foi realizado em um grande hospital cardiovascular na China, sendo que as estratégias clínicas de cardiologistas e cirurgiões podem diferir daquelas de outros hospitais na China. Embora tendo realizado pareamento por escore de propensão para ajustar para potenciais fatores de confusão nos pacientes dos grupos ICP e CRM, houve viés de seleção inicial e algumas variáveis não foram medidas.

 Conclusão

Nossa pesquisa mostrou a existência de disparidade entre os pacientes dos grupos ICP e CRM quanto ao cumprimento de meta dos fatores de risco para DAC. A prevenção secundária é crítica para a redução de desfechos após revascularização. Além disso, o cumprimento das metas dos fatores de risco diferiu entre pacientes ≥ 60 e < 60 anos de idade, mulheres e homens, sugerindo que cardiologistas e cirurgiões cardíacos devam prestar mais atenção a esses grupos de pacientes, tomando decisões clínicas corretas no processo de prevenção secundária, garantindo, assim, a tais pacientes melhor prognóstico e maiores benefícios clínicos.

Fontes de financiamento

O presente estudo foi financiado pelo National Nature Science Foundaction of China (Nº. 81270380).

Vinculação acadêmica

Não há vinculação deste estudo a programas de pós-graduação.