Understanding long-term risk in Percutaneous Coronary Intervention (PCI) in the Australian contemporary era with a focus on defining Complex Revascularisation in High-Risk Indicated Patients (CHIP)

Julian Yeoh; Garry W Hamilton; Diem Dinh; Angela Brennan; Christopher M Reid; Dion Stub; Melaine Freeman; Martin Sebastian; Ernesto Oqueli; Andrew Ajani; Tim Scully; Liam Toner; Sandra Picardo; Mark Horrigan; Matias B Yudi; Omar Farouque; Siven Seevanayagam; David J Clark; Melbourne Interventional Group

doi:10.1016/j.carrev.2024.11.001

Understanding long-term risk in Percutaneous Coronary Intervention (PCI) in the Australian contemporary era with a focus on defining Complex Revascularisation in High-Risk Indicated Patients (CHIP)

Cardiovasc Revasc Med. 2024 Nov 8:S1553-8389(24)00714-0. doi: 10.1016/j.carrev.2024.11.001. Online ahead of print.

Authors

Julian Yeoh¹, Garry W Hamilton¹, Diem Dinh², Angela Brennan², Christopher M Reid³, Dion Stub⁴, Melaine Freeman⁵, Martin Sebastian⁶, Ernesto Oqueli⁷, Andrew Ajani⁸, Tim Scully⁹, Liam Toner⁹, Sandra Picardo⁹, Mark Horrigan⁹, Matias B Yudi¹, Omar Farouque¹, Siven Seevanayagam¹, David J Clark¹⁰; Melbourne Interventional Group

Affiliations

¹ Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia.
² Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia.
³ Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; School of Population Health, Curtin University, Perth, Western Australia, Australia.
⁴ Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia.
⁵ Department of Cardiology, Box Hill Hospital, Melbourne, Australia.
⁶ Department of Cardiology, University Hospital, Geelong, Australia.
⁷ Department of Cardiology, Grampians Health Ballarat, Ballarat, Australia.
⁸ Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.
⁹ Department of Cardiology, Austin Health, Melbourne, Australia.
¹⁰ Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia. Electronic address: david.clark@austin.org.au.

PMID: 39532593
DOI: 10.1016/j.carrev.2024.11.001

Abstract

Background: Complex Revascularisation in High-Risk Indicated Patients (CHIP) is emerging in Percutaneous Coronary Intervention (PCI). We document the frequency and outcomes following CHIP PCI in the Australian population, to understand risk and guide clinical decision-making. We propose a scoring system to define CHIP procedures.

Methods: Patients undergoing PCI from Melbourne Intervention Group registry between 2005 and 2018 were analysed. Patients were stratified based on the number of high-risk features defined as 1)presence of ≥3 patient factors including age > 75yo, COPD, diabetes, renal impairment (eGFR<60 mL/min/1.73 m2), PVD, and 2)LVEF<30 %, and/or 3)having one complex coronary anatomical feature such as LMCA PCI, ACC/AHA B2/C lesion PCI, presence of multi-vessel disease or CTO PCI. National Death Index linkage was performed for long-term mortality analysis. Outcomes were analysed according to 4 risk categories - low risk(score 0), intermediate risk(score 1), high-risk(score 2), and very high-risk(score 3).

Results: 20,973patients were analysed. Majority of patients underwent intermediate-risk procedures(71.7 %), with low rates of high-risk(6.6 %), and very high-risk(0.2 %). Lesion success inversely correlates with risk; low-risk(99.4 %), intermediate-risk(95.1 %), high-risk(94.3 %), very high-risk(92.5 %),p < 0.001. In-hospital and 30-day death correlates with risk; low-risk(0.0 %/0.1 %), intermediate-risk(0.3 %/0.5 %), high-risk(1.5 %/2.9 %), very high-risk(2.4 %/7.1 %),p < 0.001. Long-term mortality correlates with risk; low-risk(12.3 %), intermediate-risk(15.8 %), high-risk(49.3 %), very high-risk(76.2 %),p < 0.001. On multivariate analysis, increasing risk correlates with long-term mortality; intermediate-risk(HR1.41), high-risk(HR6.42), and very high-risk(14.05).

Conclusion: In the Australian practice, proportion of patients undergoing high and very high-risk PCI procedures are low. Despite good procedural success and in-hospital outcomes, long-term mortality is poor. Further research into appropriate patient selection, and direct comparison of CHIP PCI to those treated medically and surgically should be considered.

Keywords: Complex high-risk and indicated patients; Percutaneous coronary intervention.