Percutaneous coronary intervention reduced mortality in acute coronary syndrome (aHR 0.58), though no significant survival benefit was seen in unstable angina or NSTEMI with reduced LVEF.
Does percutaneous coronary intervention (PCI) reduce all-cause mortality in patients with acute coronary syndrome (ACS) across different levels of left ventricular ejection fraction (LVEF)?
While PCI improves long-term survival in most ACS patients, the mortality benefit may be attenuated or absent in those with NSTEMI and reduced LVEF (≤40%) or unstable angina.
Absolute Event Rate: 0% vs 0%
Abstract Background The impact of percutaneous coronary intervention (PCI) on long-term survival after acute coronary syndrome (ACS) across different levels of left ventricular ejection fraction (LVEF) remains incompletely understood. Purpose To evaluate the association between PCI and mortality after ACS, and to examine potential effect modification by LVEF and ACS type. Methods We analysed ACS cases from the multicentre CardioMining-AI study with available follow-up data. The primary exposure was PCI during the index admission, and the outcome was all-cause mortality. Associations were evaluated using Cox proportional hazards models (inverse probability of treatment weighting IPTW-weighted), with an interaction term between PCI and LVEF (≤40% vs 40%). Missing LVEF values were handled by multiple (n=50) imputation. Sensitivity analyses included complete-case, propensity-matched, and unweighted models. Subgroup analyses were stratified by ACS type. IPTW-weighted Kaplan–Meier (KM) curves and log-rank tests illustrated survival differences between treatment groups across ACS type and LVEF. Results Among 4446 ACS patients (age 66 ± 13 years, 75% male), 2393 (54%) underwent PCI during the index admission. During a median follow-up of 4.6 years (IQR 2.7–6.4), 1336 deaths (30.0%) occurred. In the primary model (Figure 1), PCI was independently associated with lower mortality (adjusted hazard ratio aHR 0.58, 95% CI 0.48–0.70; p0.001). Age, chronic kidney disease, type 2 diabetes, and prior ACS were also independent predictors of mortality. There was no significant interaction between PCI and LVEF (p=0.12). When stratified by LVEF, PCI was clearly associated with reduced mortality in LVEF40% (aHR 0.56, 95% CI 0.44–0.72), but a weaker, non-significant effect was observed in LVEF≤40% (aHR 0.85, 95% CI 0.48–1.51). Sensitivity analyses were consistent. Weighted KM curves showed clear survival separation for PCI across the combined ACS cohorts (all p0.001). Subgroup analyses revealed heterogeneity by ACS type. In ST-elevation myocardial infarction (STEMI), PCI was associated with substantially lower mortality (aHR 0.60, 95% CI 0.41–0.88; p=0.010), consistent across LVEF strata (interaction p=0.90). In non-STEMI (NSTEMI), PCI was also linked to improved survival (aHR 0.56, 95% CI 0.44–0.72; p0.001), but this benefit was attenuated in patients with reduced LVEF. In unstable angina (UA), PCI showed no significant association with mortality (aHR 0.76, 95% CI 0.54–1.08; p=0.13). KM curves further illustrated the absence of survival benefit in NSTEMI with LVEF≤40% and in UA across all LVEF levels (Figure 2). Conclusions While PCI was generally associated with improved survival after ACS, no clear mortality benefit was observed in patients with NSTEMI and reduced LVEF or in UA. These findings highlight potential limits of revascularisation benefit in these subgroups and suggest the need for refined risk stratification and patient selection strategies.1)Post-ACS mortality predictors and LVEFFor image description, please refer to the figure legend and surrounding text. 2)Survival per ACS, PCI status, and LVEFFor image description, please refer to the figure legend and surrounding text.
Tsiartas et al. (Sun,) reported a other. Percutaneous coronary intervention reduced mortality in acute coronary syndrome (aHR 0.58), though no significant survival benefit was seen in unstable angina or NSTEMI with reduced LVEF.