CRT: Patient characteristics better predict outcomes than treatment choice for CTOs

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WASHINGTON, D.C.—In patients with coronary chronic total occlusion (CTO) lesions, the one-year outcomes are related to their clinical characteristics rather than to treatment strategy used, according to the results of the IRCTO registry, presented Feb. 27 at the 2011 Cardiovascular Research Technologies (CRT) annual meeting. Also, the prevalence of coronary CTO lesions was 12.3 percent in the registry population, who all had known coronary artery disease, but the lead investigator stressed the rate would be higher in the overall cath lab population.

More physicians are seeking to treat CTOs than in the past because the success rates are higher, lead investigator Alfredo R. Galassi, MD, head of the cardiac catheterization and interventional cardiology unit at Ferrarotto Hospital in Catania, Italy, told Cardiovascular Business News. “Also, treating CTOs is leading to improved patient conditions.” Galassi presented his results on behalf of the IRCTO investigators.

However, there are a great many unknowns with CTO lesions. Therefore, Galassi and his colleagues sought to assess the prevalence, demographics, clinical characteristics and therapeutic strategy of patients with CTOs, in an effort to improve their management.

In phase one of the registry, the researchers enrolled all patients with at least one CTO in a main coronary artery ( >three months duration with vessel size >2.5 mm) during angiography. The therapeutic strategy of optimal medical therapy, PCI or CABG was chosen independently.

Twelve centers throughout Italy have enrolled 1,777 patients, recording a CTO prevelance rate of 12.3 percent. Galassi hypothesized that the CTO prevalence rate would be higher if the overall cath lab population was included in the registry, and not simply patients with known coronary artery disease. “It may jump from 12.3 percent to 20 percent,” he said.

Based on the angiographic characteristics, the total number of CTOs was 1,968, with 1,596 patients with single-vessel CTOs, 171 with two-vessel CTOs and 10 with three-vessel CTOs.

Of these patients, 776 received PCI. The PCI group was slightly younger. Also, the researchers learned that these patients who also had three-vessel disease or a lower left ventricular ejection fraction were more often treated with optimal medical therapy or surgery. In fact, only for the patient population with LVEF of more than 50 percent did the majority of patients receive PCI.

Also, the majority of patients with stable angina received PCI, and the majority of acute MI patients received optimal medical therapy.

Galassi et al found that clinical characteristics, such as age, ejection fraction and multivessel disease, were stronger multivariate predictors of hard events at one year than the treatment strategy. Also, between the treatment groups, there wasn’t much difference in the symptoms at one year.

At one year, the researchers found that patients with successful PCI have better outcomes than those with unsuccessful PCI. Successful PCI occurred in 75 percent of the patients. “Successful PCI was associated with the best survival free from hard events on an adjusted Kaplain-Maier curve, compared with optimal medical therapy and surgery,” Galassi reported.

In order to properly treat this population, Galassi and his colleagues are forming a dedicated team of specialists who will treat these patients. After a survey of the CRT audience, it was revealed that more often practices have one physician who specializes in treating CTO lesions.