Thread by @lamelaspablo

Readdressing the validity of repeat revascularization as an outcome measure in #PCI Vs #CABG. For readers in a hurry:
1) visit @cardiomicsclub cardiomics.club/2019/12/20/rea…
2) go to @JACCJournals and listen podcast onlinejacc.org/content/74/25/…
3) read this thread! (Laziest!)

Repeat revasc has been used in multiple #PCI Vs #CABG RCTs, consistently favoring CABG, making composite outcomes mostly influenced by repeat revasc in many scenarios. Also, repeat revasc has been cited as (at least part of) the justification for recommending CABG over PCI

However, repeat revasc (alone, no associated MI) has many clinical and methdological limitations warranting deep understanding for an appropriate appraisal, summarized in this slide. First one is confounding by indication: repeat revasc is indicated, does not happen spontaneously

After PCI, the use if stress test is more frequent (as per guideline recs plus what happens in clinical practice). Thus, silent ischemia (or non-prognostically important ischemia, or false positives, etc) more likely to be found after a PCI than a CABG.

But more importantly, patients receiving a repeat revasc after CABG had much worse clinical (symptom) decline than post PCI patients in the SYNTAX trial, evidencing VERY different thresholds for advancing patients to further revasc procedures by practice @arnoldgehrke @djc795

repeat revasc after PCI is mostly driven by target lesion revasc. Interestingly, despite non-LIMA-grafts tend to have lower patency (ie: occlusion) than DES at one-year, stent failure is revascularized more frequently than bypass failure, why?

🤔 bypasses promote CAD progression in their territories (5-10x), then, degenerated/occluded grafts have less suitable native CAD for PCI and usually managed medically (80%+ post CABG with >=1 graft occlusion had no suitable targets for revasc), and graft PCI 👎 @SVRaoMD

Also, is unknown the magnitude of the causal (independent) impact of future repeat revasc on subsequent MI/death/other outcomes, since most of the effect is mediated by concomitant myocardial infarction.

Finally, patient preferences. Repeat revasc is out of proportion to death/stroke/MI, and most (50%+) patients still prefer multivessel PCI than CABG despite being informed of 2x mortality or 3x repeat revasc risk with PCI

Recommendation: still measure repeat revasc in PCI vs CABG trials, but dont pool it (so, no inclusoon of repeat revasc in primary composite outcomes) and interpret in context of the limitations (preferences and biases) described above.

Bet u debated this topic with colleages!👌@mmamas1973 @rahatheart1 @RodrigoBagur @DocSavageTJU @DavidLBrownMD @mirvatalasnag @pomyers @willsuh76 @omendiz @INC_CathLab @jpdebrahi @evandrofilhobr @ajaykirtane @Babar_Basir @DrMauricioCohen @GilbertTangMD @ekgpdx @DrMarthaGulati