Letter to Editor,
With great interest, I read the manuscript entitled: “Long-term improvement of symptoms of angina pectoris after successful revascularization of coronary artery chronic total occlusions” [Citation1]. The authors state strongly in conclusion that “Successful CTO PCI improved symptoms with a lasting effect up to 37 months, and a failed CTO PCI intervention as independent predictors of poor long-term symptom relief. In addition, the rate of in-hospital complications after CTO PCI was reported to be low”. This study and its conclusions are classic for underreporting complications and exaggerating benefits. Furthermore. The effect of a placebo on the long-term angina benefit is also completely ignored. They admitted that unsuccessful CTO PCI had a perforation rate of 3.0 vs 0.4% proving the fact that the unsuccessful PCI arm underwent trauma and harm that could explain a higher long-term MACE rate reported in this study. The author reports a staggering MACE rate of 23% in successful CTO PCI and even much higher, 63% in unsuccessful PCI arms. These are very high unacceptable MACE rates in both groups. MACE rate of stable angina patients (CTO belonging to stable angina patients) on medical therapy is very low [Citation2–3]. Having such a high MACE rate should forbid CTO PCI. How could the authors discuss the benefit of CTO PCI with so many MACEs occurring in both groups? Unfortunately, underreported harms in patients undergoing CTO PCI and exaggerating benefits is a very common practice. There are now plenty of studies showing no improvement in mortality in patients undergoing CTO PCI and other soft points are also in question [Citation2–4]. We have published the largest CTO outcome data involving 259,574 CTO interventions showing higher all-cause inpatient mortality and complications in patients undergoing CTO PCI compared to other PCIs [Citation5]. The CTO cohort had a 3.17% mortality rate in comparison to a mortality rate of 2.57% of other PCIs. (OR:1.24; CI]: 1.18–1.31; p < .001). Compared to other PCIs, all postprocedural complications were more than 3 times higher in CTO PCI patients. Therefore, there should be a word of caution and CTO PCI should only be performed in a patient with resistant limiting angina despite maximal medical therapy and is aware that CTO PCI does not improve long-term mortality and that PCI CTO is a high-risk procedure. We recently alerted physicians about this problem [Citation6]. Being inertia is not an option and cardiology journals have to be more active in this regard. We need accountability for too many unnecessary CTO PCIs that are being performed leading to great harm [Citation7].
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References
- Miyashita H, Mansikkaniemi L, Sinisalo J, et al. Long-term improvement of symptoms of angina pectoris after successful revascularization of coronary artery chronic total occlusions. Scand Cardiovasc J. 2023;57(1):2161621. doi:10.1080/14017431.2022.2161621.
- Boden WE, O'Rourke RA, Teo KK, COURAGE Trial Investigators., et al. Impact of optimal medical therapy with or without Percutaneous coronary intervention on long-term cardiovascular end points in patients with stable coronary artery disease (from the COURAGE Trial). Am J Cardiol. 2009;104(1):1–4. doi:10.1016/j.amjcard.2009.02.059.
- Stergiopoulos K, Boden WE, Hartigan P, et al. Percutaneous coronary intervention outcomes in patients with stable obstructive coronary artery disease and myocardial ischemia: a collaborative meta-analysis of contemporary randomized clinical trials. JAMA Intern Med. 2014;174(2):232–240. doi:10.1001/jamainternmed.2013.12855.
- Kim MH, Mitsudo K, Jin CD, et al. Long-term clinical outcomes after successful and failed recanalization to native chronic Total occlusion: insights from the Busan chronic Total occlusion (B-CTO) Registry. Cardiovasc Revasc Med. 2016; Jun17(4):229–232. doi:10.1016/j.carrev.2016.02.011.
- Nathan A, Hashemzadeh M, Movahed MR, et al. Percutaneous coronary intervention of chronic total occlusion associated with higher inpatient mortality and complications compared with non-CTO lesions. Am J Med. 2023;136(10):994–999. doi:10.1016/j.amjmed.2023.06.004.
- Movahed MR. Significant downplay and underreporting of adverse events in patients who underwent percutaneous coronary intervention of chronic total occlusions. Am J Cardiol. 2023;210:317. doi:10.1016/j.amjcard.2023.10.023.
- Movahed MR. It is time to have better oversite and accountability in performing too many not indicated percutaneous coronary interventions in patients with chronic total occlusions. Int J Cardiol. 2019;278:38–39. doi:10.1016/j.ijcard.2018.11.122.