Difference in Patient Profiles and Outcomes in Japanese Versus American Patients Undergoing Coronary Revascularization (Collaborative Study by CREDO-Kyoto and the Texas Heart Institute Research Database)

doi:10.1016/j.amjcard.2010.01.349

The American Journal of Cardiology

Volume 105, Issue 12, 15 June 2010, Pages 1698-1704

https://doi.org/10.1016/j.amjcard.2010.01.349 Get rights and content

Although coronary revascularization is common in both Japan and the United States (US), no direct comparison has been performed to demonstrate differences in the clinical characteristics and long-term outcomes of patients in these 2 countries. We analyzed the preprocedural, in-hospital, and long-term data from the Coronary Revascularization Demonstrating Outcome registry (Kyoto, Japan) and the Texas Heart Institute Research Database (Houston, Texas) of 16,100 patients who had undergone elective, initial percutaneous coronary intervention or coronary artery bypass grafting. The Japanese procedures were performed from 2000 to 2002 (n = 8,871, follow-up period 3.5 years, interquartile range 2.6 to 4.3) and the US procedures from 1999 to 2003 (n = 7,229, follow-up period 5.2 years, interquartile range 3.8 to 6.5). The Japanese patients tended to be older (mean age 67.2 vs 62.7 years; p <0.001), to smoke (52.9% vs 46.0%; p <0.001), and to have diabetes (39.2% vs 31.0%; p <0.001) and stroke (16.4% vs 5.0%; p <0.001). The US patients were more obese (body mass index 23.7 vs 29.3 kg/m²; p <0.001), with greater rates of systemic atherosclerotic disease. Both groups had a similar in-hospital mortality rate (Japanese patients 0.9% vs US patients 1.1%; p = 0.19) and crude long-term mortality rate (Japanese patients 27.7/1,000 person-years, US patients 28.2/1,000 person-years; p = 0.35). After adjustment for known predictors, the US group had greater long-term mortality than the Japanese group (hazard ratio 1.71, 95% confidence interval 1.50 to 1.95; p <0.001). This finding was consistent among all high-risk subgroups. In conclusion, the 2 registries showed similar crude outcomes but important differences in patient risk factors such as obesity. In the adjusted analysis, the Japanese patients had better outcomes than did the US patients. Additional study is needed to assess the effect of ethnic and risk factor variations on coronary artery disease.

Section snippets

Methods

The Coronary Revascularization Demonstrating Outcome database in Kyoto (CREDO-Kyoto) was a multicenter (n = 29) registry maintained in Kyoto, Japan. The Texas Heart Institute Research Database (THIRDBase) is an ongoing single-center registry maintained at the Texas Heart Institute in Houston, Texas. Details concerning the design of the CREDO-Kyoto and THIRDBase have previously been reported.5, 6 Both of these comprehensive, longitudinal, clinical registries of patients undergoing coronary

Results

The series included 16,100 patients—8,871 patients from the CREDO-Kyoto registry (median follow-up period 3.5 years, interquartile range 2.6 to 4.3) and 7,229 patients from the THIRDBase registry (median follow-up period 5.2 years, interquartile range 3.8 to 6.5). The Japanese patients were older and were more likely to be smokers and to have diabetes mellitus and cerebrovascular disease (Table 1). The US patients were more obese, with a greater body mass index. In general, the US patients had

Discussion

We used information from 2 well-established registries, CREDO-Kyoto and THIRDBase, to compare the clinical characteristics and outcomes of patients undergoing coronary revascularization in Japan versus the US. The present study involved a large number of patients (>8,000), a high rate of clinical follow-up observation, and an excellent database infrastructure and support system. Although the long-term outcomes were similar with regard to crude mortality, they appeared to favor the Japanese

Acknowledgment

The authors thank Virginia Fairchild, MB, of the Texas Heart Institute Department of Scientific Publications, for editorial assistance in preparing this report.

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As a result, the majority of the included studies was derived within Asian populations. Differences in underlying epidemiology (incidence, risk factors) of cardiovascular disease and patient demographics, along with differences in plaque and lesion phenotype between Asian and Western populations, should therefore be considered [36–38]. Intracoronary imaging studies have shown differences in plaque morphology between both ethnicities, with Western patients having higher lipid indexes, higher plaque burden, more calcification and longer lesion lengths as compared to Asian populations [39,40].
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We systematically searched Embase, MEDLINE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar for studies that compared clinical outcomes for IVUS- versus angio-guided PCI in patients with AMI. The primary endpoint was all-cause mortality and the secondary endpoint major adverse cardiovascular events (MACE). Mantel-Haenszel random-effects model was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI).
Nine studies (8 observational, 1 RCT) with a total of 838.902 patients (796.953 angio-guided PCI, 41.949 IVUS-guided PCI) were included. In patients with AMI, IVUS-guided PCI was associated with a significantly lower risk of all-cause mortality (pooled RR: 0.70; 95% CI, 0.59–0.82; p < 0.01), MACE (pooled RR: 0.86; 95% CI, 0.74–0.99; p = 0.04) and target vessel revascularization (TVR) (pooled RR: 0.83; 95% CI, 0.73–0.95; p < 0.01). In the subset of patients presenting with ST-segment elevation, IVUS-guided PCI remained associated with a reduced risk for both all-cause mortality (pooled RR: 0.79; 95% CI, 0.66–0.95, p = 0.01) and MACE (pooled RR: 0.86; 95% CI, 0.74–0.99, p = 0.04).
This is the first systematic review and meta-analysis comparing IVUS- versus angio-guided PCI in patients with AMI, showing a beneficial effect of IVUS-guided PCI on all-cause mortality, MACE and TVR. Results of ongoing dedicated prospective studies are needed to confirm these findings.
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Acute coronary syndromes (ACS) are one of the most frequent conditions for admission to cardiology worldwide. Ethnic differences in the prevalence of cardiovascular risk factors,1,2 coronary atherosclerosis patterns,3–5 ischemic heart disease presentation,6,7 response to cardiovascular medications,8 and outcomes after myocardial infarction and revascularization9,10 have been reported between 2 of the world's largest ethnic groups: Asians and Whites. Little is known about the differences in the pathobiology of ACS between these 2 ethnic groups.
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Citation Excerpt :
However, few data exist regarding bleeding complications after PCI in the Asian population, and the Asian subgroup has been relatively small in previous large-scale registry studies conducted in Western countries [14]. Given the differing risk profiles between Japanese patients and those in the Western population [15,16], the incidence and predictors of bleeding complications after PCI need to be assessed independently in Japan. In addition, efforts to reduce bleeding complications and precise risk prediction remain of major importance.
Bleeding complications remain one of the most important challenges in percutaneous coronary intervention (PCI), particularly in Asians who are known to be vulnerable to the use of antiplatelets or anticoagulants. However, the incidence and predictors of bleeding complications after PCI have not been thoroughly investigated in Japan.
We studied 13,075 consecutive patients in a Japanese multicenter PCI registry (Japan Cardiovascular Database – Keio interhospital Cardiovascular Study: JCD-KiCS) from September 2008 to March 2014. Multivariate logistic regression analysis was performed to investigate independent predictors of bleeding complications, and to create three risk prediction models for bleeding events. Model 1 included patients’ characteristics alone. In model 2, we added patients’ clinical presentation. Model 3 included covariates in model 2 along with angiographic and technical factors. Model discrimination was assessed using the area under the receiver operating curve (AUC).
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Dr. Kohsaka is currently appointed with Keio University, School of Medicine, Tokyo, Japan.

This work was supported by an educational grant from the Research Institute for Production Development (Kyoto, Japan), Grant-in-Aid for Young Scientist (KAKENHI) from the Ministry of Education, Culture, Sports, Science and Technology (Tokyo, Japan) and the Grant for Clinical Vascular Function Kimura Memorial Cardiovascular Foundation (Tokyo, Japan).

: Drs. Kohsaka and Goto had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Coronary artery diseaseDifference in Patient Profiles and Outcomes in Japanese Versus American Patients Undergoing Coronary Revascularization (Collaborative Study by CREDO-Kyoto and the Texas Heart Institute Research Database)

Section snippets

Methods

Results

Discussion

Acknowledgment

Am J Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Review article: diabetes, genetics and ethnicity

Aliment Pharmacol Ther

Health: United States 2005 with Chartbook on Trends in the Health of Americans

Mayo Clinic risk score for percutaneous coronary intervention predicts in-hospital mortality in patients undergoing coronary artery bypass graft surgery

Circulation

Long-term outcomes of coronary-artery bypass graft surgery versus percutaneous coronary intervention for multivessel coronary artery disease in the bare-metal stent era

Circulation

Racial differences in risk factors for atherosclerosis: the ARIC studyAtherosclerosis Risk in Communities

Angiology

Coronary artery disease
Difference in Patient Profiles and Outcomes in Japanese Versus American Patients Undergoing Coronary Revascularization (Collaborative Study by CREDO-Kyoto and the Texas Heart Institute Research Database)