USA: Findings from a 5-Year Follow-Up of the EXCEL Trial

Findings from a 5-year follow-up of the EXCEL trial revealed that surgery has the upper hand over angioplasty for revascularization for left main coronary disease concerning hospital readmission rates.

The study was published online in the Journal of the American College of Cardiology.

In the EXCEL trial, readmission during 5-year follow-up after revascularization for left main coronary artery disease (LMCAD) was common and more frequent after percutaneous coronary intervention (PCI) than coronary artery bypass grafting (CABG). Readmissions were tied to an increased risk of all-cause death, more so after PCI than with CABG.

"This thought-provoking analysis highlights the risks and implications of late readmissions after revascularization for unprotected left main coronary artery disease," Wayne B. Batchelor and Abdulla A. Damluji from Inova Schar Heart and Vascular in Falls Church, Virginia, wrote in an accompanying editorial.

The frequency of and the relationship between hospital readmissions and outcomes following revascularization for left main coronary artery disease are unknown. Ioanna Kosmidou, from Cardiovascular Research Foundation in New York, New York, USA, and colleagues aimed to study the predictors, incidence, and clinical impact of readmissions following PCI and coronary artery bypass grafting for LMCAD.

In the EXCEL trial, 1,905 patients with LMCAD were randomized to percutaneous coronary intervention versus coronary artery bypass grafting.

The cumulative incidence of readmissions was analyzed with multivariable Anderson-Gill and joint frailty models to consider recurrent events and the competing risk of death. A time-adjusted Cox proportional hazards model determined the impact of readmission on subsequent mortality within 5-year follow-up.

Study Findings

• Within 5 years, 1,868 readmissions occurred in 45.2% of hospital survivors (2.2 ± 1.9 per patient with readmission[s], range 1-16), approximately one-half for cardiovascular causes and one-half for noncardiovascular causes (49.6% and 50.4%, respectively).
• One or more readmissions occurred in 48.6% of PCI patients versus 41.8% of CABG patients.
• After multivariable adjustment, PCI remained an independent predictor of readmission (adjusted HR: 1.22), along with female sex, comorbidities, and the extent of CAD.
• Readmission was independently associated with subsequent all-cause death, with interaction testing indicating a higher risk after PCI than CABG (adjusted HR: 5.72 vs adjusted HR: 2.72, respectively).

"PCI was an independent predictor of readmission and associated with a higher readmission rate than CABG," the study authors concluded.

Reference

DOI: https://www.jacc.org/doi/10.1016/j.jacc.2024.01.012