Abstract 4361559: Optimal Medical Therapy and Uncontrolled Risk Factors in Patients with Chronic Coronary Syndrome Undergoing PCI: Temporal Trends and Clinical Outcomes

Abstract

Background: Despite guidelines recommending revascularization for refractory angina after optimal medical therapy (OMT) in chronic coronary syndrome patients (CCS), limited studies indicate these recommendations have minimally influenced clinical practice. Research Question: We sought to assess trends in real-world OMT management and risk factor control, and their impact on outcomes in patients with CCS undergoing PCI. Method: We performed a retrospective analysis of patients with CCS and documented positive stress test undergoing PCI at Mount Sinai Hospital in New York between 2012 and 2023. Patients were stratified according to numbers of class of cardiovascular medications (meds, Figure 1A) and uncontrolled cardiometabolic risk factors (URF, Figure 1B) at admission. The URF group comprised low, intermediate, and high-risk categories, while the meds group consisted of low, moderate, and high-intensity treatment categories (Figure 2). The primary outcome was unadjusted MACE (composite of all-cause death, MI, stroke, or TVR) assessed at 1 year follow-up. Results: Of 9,766 patients included, the mean age was 67.0±10.5 years; 27.1% were female; 63.0% presented with multi-vessel disease; 50.4% were intermediate risk; 13.3% were high risk; 38.3% were receiving moderate intensity treatment; and 45.9% were receiving high intensity treatment. Hyperlipidemia and obesity were the most prevalent URF at presentation and the most common combination of meds reported included antithrombotic, antianginal, lipid-lowering, and RAAS inhibitors (Figure 1A-B). There was significant increase in the number of patients presenting with improved URF and high-intensity treatment over time (Figure 2). At 1 year, high risk group had higher MACE compared to low risk group (10.8% vs. 7.9%, HR 1.39, 95% CI 1.12 – 1.74, P = 0.003), mainly due to MI (2.3% vs. 0.8%, HR 2.91, 95% CI 1.66 – 5.09, P < 0.001). Similarly, high intensity treatment group had higher MACE at 1 year than low intensity group (9.5% vs. 6.8%, HR 1.40, 95% CI 1.11 – 1.76, P = 0.004), but lower all-cause death (1.1% vs. 1.8%, HR 0.59, 95% CI 0.36 – 0.98, P = 0.041). No difference in MACE among intermediate and moderate groups (URF and meds). Conclusion: In CCS patients undergoing PCI, OMT and risk factor control improved over time. At 1 year, MACE was higher in both high risk and high intensity treatment groups, but all-cause death was lower in the high intensity treatment group.