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Prognostic Role of Restenosis in 10,004 Patients Undergoing Routine Control Angiography After Coronary Stenting
Study Questions:
What is the prognostic importance of stent restenosis detected on routine surveillance angiography?
Methods:
The authors reported on outcome of consecutive patients who underwent successful implantation of coronary stents for de novo lesions from 1998 to 2009, and then had routine control angiography after 6-8 months at two centers in Munich, Germany. Restenosis was defined as diameter stenosis ≥50% in the in-segment area at follow-up angiography. The primary outcome was 4-year mortality.
Results:
The study included 10,004 patients who underwent stent placement for 15,004 lesions. Restenosis was detected in 2,643 (26.4%) patients and the morphology was 34% focal body, 15% focal margin, 5% multifocal, 38% diffuse, 2% proliferative, and 5% occlusive. Overall, there were 702 deaths during the follow-up. Patients with restenosis were at higher risk of death on follow-up (unadjusted hazard ratio [HR], 1.19; 95% confidence interval [CI], 1.02-1.40; p = 0.03). Restenosis was an independent predictor of 4-year mortality after adjusting for other baseline variables (HR, 1.23; 95% CI, 1.03-1.46; p = 0.02). Other independent correlates of 4-year mortality were age (for each 10-year increase: HR, 2.34; 95% CI, 2.12-2.60; p < 0.001), diabetes mellitus (HR, 1.68; 95% CI, 1.41-1.99; p < 0.001), current smoking (HR, 1.39; 95% CI, 1.09-1.76; p = 0.01), and left ventricular ejection fraction (for each 5% decrease: HR, 1.39; 95% CI, 1.31-1.48; p < 0.001). There was no difference in the long-term survival of patients with restenosis who did and did not undergo revascularization.
Conclusions:
The authors concluded that restenosis is an independent predictor of long-term survival in patients undergoing coronary stenting.
Perspective:
This study demonstrates that restenosis is an independent marker of prognosis in patients treated with stents. It is unclear if restenosis is a mediator or simply a marker of poor long-term survival. It is possible that patients who develop restenosis have more aggressive coronary artery disease and restenosis is simply a surrogate for more complex coronary artery pathology. In this study, revascularization was not associated with an improvement in outcome, suggesting that the ischemic burden imposed by the restenosis is unlikely to be contributing directly to this mortality hazard. This study raises interesting questions, but it would be premature to treat restenosis any differently than recommended by current guidelines.
Keywords: Coronary Artery Disease, Follow-Up Studies, Coronary Restenosis, Stroke Volume, Constriction, Pathologic, Diabetes Mellitus, Angiography, Smoking, Stents
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