Mayo Clinic Proceedings: Innovations, Quality & Outcomes (Dec 2021)

Modifiable Risk Factors and Residual Risk Following Coronary Revascularization

  • Trevor Simard, MD,
  • Richard G. Jung, PhD,
  • Pietro Di Santo, MD,
  • David T. Harnett, MD, MSc,
  • Omar Abdel-Razek, MD,
  • F. Daniel Ramirez, MD, MSc,
  • Pouya Motazedian, MD,
  • Simon Parlow, MD,
  • Alisha Labinaz, BSc,
  • Robert Moreland, MD,
  • Jeffrey Marbach, MBBS, MS,
  • Anthony Poulin, MD,
  • Amos Levi, MD,
  • Kamran Majeed, MD,
  • Paul Boland, MD, PhD,
  • Etienne Couture, MD,
  • Kiran Sarathy, MD,
  • Steven Promislow, MD,
  • Juan J. Russo, MD,
  • Aun Yeong Chong, MD,
  • Derek So, MD,
  • Michael Froeschl, MD,
  • Alexander Dick, MD,
  • Marino Labinaz, MD,
  • Michel Le May, MD,
  • David R. Holmes, Jr., MD,
  • Benjamin Hibbert, MD, PhD

Journal volume & issue
Vol. 5, no. 6
pp. 1138 – 1152

Abstract

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Objective: To ensure compliance with optimal secondary prevention strategies and document the residual risk of patients following revascularization, we established a postrevascularization clinic for risk-factor optimization at 1 year, with outcomes recorded in a web-based registry. Although coronary revascularization can reduce ischemia, medical treatment of coronary artery disease (CAD) remains the cornerstone of ongoing risk reduction. While standardized referral pathways and protocols for revascularization are prevalent and well studied, post-revascularization care is often less formalized. Patients and Methods: The University of Ottawa Heart Institute is a tertiary-care center providing coronary revascularization services. From 2015 to 2019, data were prospectively recorded in the CAPITAL revascularization registry, and patient-level procedural, clinical, and outcome data are collected in the year following revascularization. Major adverse cardiovascular event (MACE) was defined as death, myocardial infarction, unplanned revascularization, or cerebrovascular accident. Kaplan-Meier curves were generated to evaluate time-to-event data for clinical outcomes by risk-factor management, and comparisons were performed using log-rank tests and reported by hazard ratio (HR) and 95% confidence intervals (CIs). Results: A cohort of 4147 patients completed 1-year follow-up after revascularization procedure that included 3462 undergoing percutaneous coronary intervention (PCI), 589 undergoing coronary artery bypass graft (CABG), and 96 undergoing both PCI and CABG. In the year following revascularization (median follow-up 13.3 months—interquartile range [IQR]: 11.9-16.5) 11% of patients experienced MACE, with female patients being disproportionately at risk. Moreover, 47.7% of patients had ≥2 risk factors (diabetes, dyslipidemia, overweight, active smoker) at the time of follow-up, with 45.0% of patients with diabetes failing to achieve target hemoglobin (Hb) A1c, 54.8% of smokers continuing to smoke, and 27.1% of patients failing to achieve guideline-directed lipid targets. Conclusion: Patients who have undergone revascularization procedures remain at elevated risk for MACE, and inadequately controlled risk factors are prevalent in follow-up. This highlights the need for aggressive secondary prevention strategies and implementation of programs to optimize postrevascularization care.