Association between Gensini Score and Major Adverse Cardiovascular Events in Patients Undergoing Left Heart Catheterization: A Single Center Experience Open Access

Abstract

Background: Coronary artery disease (CAD) poses a major health burden worldwide. Left heart catheterization (LHC) is an essential diagnostic tool for assessing the severity of CAD. The Gensini score, which is based on angiographic data, measures the extent of CAD. This study aims to examine the association between the Gensini score and Major Adverse Cardiovascular Events (MACE) and compare outcomes between treatment strategies (percutaneous coronary intervention [PCI] vs. medication) in patients undergoing LHC. Additionally, the study aims to identify the risk factors for all-cause mortality in this patient population.

Methods: This study involved a retrospective cohort analysis of 3163 participants from the Emory Cardiovascular Biobank (EmCAB) who underwent clinically indicated LHC at Emory healthcare facilities in Atlanta. Patients were divided into two groups based on the treatment they received: PCI or medication. The primary outcome was Major Adverse Cardiovascular events (MACE), which was the composite of cardiovascular death, myocardial infarction (MI), stroke, and unplanned coronary revascularization. The secondary outcome was all-cause mortality. The study examined the association between the Gensini score and primary and secondary outcomes across both treatment groups.

Results: The medication group showed a positive association between the Gensini score and MACE events [HR=1.13 per 12-point increase in Gensini score, 95% CI: (1.08, 1.18), p<0.0001]. In contrast, no association was observed between the Gensini score MACE in the PCI group [HR=1.00 per 12-point increase in Gensini score, 95% CI: (0.954, 1.041), p=0.88]. The difference in these results suggests a potential benefit from PCI. However, the overall MACE rate was higher in the PCI group compared to the medication group, possibly due to selection bias and inherent complications associated with PCI. Additionally, the Gensini score was not significantly associated with all-cause mortality in either group. As for the risk factors of all-cause mortality, age, left ventricular ejection fraction, serum creatinine, chronic kidney disease, and diabetes mellitus, with HRs of 1.17 (1.13, 1.21) for a 5-year increase; 0.88 (0.86, 0.91) for a 5% increase; 1.06 (1.04, 1.08) for a 0.5 mg/dl increase; 1.63 (1.32, 2.02); and 1.20 (1.02, 1.42), respectively.

Conclusion: This study suggests that the Gensini score can predict the risk of MACE in patients managed with medication, while PCI might mitigate this association, potentially benefiting those with severe CAD. The higher overall MACE rate in the PCI group emphasizes the need for careful patient selection. All-cause mortality appears to be less influenced by the Gensini score, highlighting the importance of addressing other risk factors. Future research should investigate the impact of residual Gensini score post-PCI on long-term outcomes and explore the role of coronary artery bypass graft surgery (CABG) in the treatment landscape.

Table of Contents

I. Introduction ........................................................................................................................ 1

o  Cardiovascular Disease (CVD) as a Public Health Issue in Georgia

o  Coronary Artery Disease (CAD) and Management Strategies

o  The Gensini Score for Assessing CAD Severity

o  Research Gap and Current Study Objectives

II. Literature Review................................................................................................................4

The Gensini Score: Development and Significance ....................................................................4

Gensini Score vs. SYNTAX Score: Complementary Strengths ..................................................... 5

Predictive Value of Gensini Score in Long-Term Outcomes Following PCI Study .......................... 7

Further Highlights of the Utility of the Gensini Score ................................................................10

Literature Review Conclusion ..................................................................................................15

III. Methodology .....................................................................................................................17

Data Source: Emory Cardiovascular Biobank (EmCAB)...............................................................17

Participants and Inclusion/Exclusion Criteria............................................................................19

Variables: Baseline Characteristics, Exposures, and Outcomes.................................................... 20

IV. Analysis ............................................................................................................................ 22

Data Presentation: Descriptive Statistics...................................................................................22

Analysis of Outcomes (MACE and All-Cause Mortality)...…………………………………….……….....…22

o  Kaplan-Meier Analysis

o  Univariate and Multivariable Cox Proportional Hazards Regression

o  Interaction Analysis

o  Missing Data Management with Multiple Imputations

o  Forest Plots for Hazard Ratios

V. Results ...............................................................................................................................24

Baseline Characteristics of Participants……………………………………………………….………..….……24

Clinical Outcomes: MACE and All-Cause Mortality ................................................................... 24

Univariate and Multivariable Analysis Findings......................................................................... 25

Key Findings for MACE ............................................................................................................ 27

Key Findings for All-Cause Mortality ........................................................................................ 29

VI. Discussion ........................................................................................................................ 32

Gensini Score and MACE Outcomes in Medication vs. PCI Groups...............................................32

Potential Mechanisms for Differential Effects............................................................................33

All-Cause Mortality and Gensini Score .....................................................................................34

Limitations of the Study...........................................................................................................34

Clinical and Public Health Implications.................................................................................... 34

VII. Conclusion .......................................................................................................................36

VIII. Tables and Figures ...........................................................................................................37

Figure 1: Flow diagram of participants’ inclusion ……………………….…………………………………….38

Table 1: Baseline Characteristics of Participants by Treatment Group…………………………………...39

Table 2: MACE and All-Cause Mortality Incidence Rates…………………………………………….………40

Table 3: Multivariable Analysis Results for MACE Risk (Including Interaction Term)………………...41

Table 4: Multivariable Analysis Results for All-Cause Mortality Risk………………………………….….42

Figure 2: Kaplan-Meier Curves for MACE by Treatment Group.…………………………….………….…..43

Figure 3: Kaplan-Meier Curves for All-Cause Mortality by Treatment Group….………………………..44

Figure 4_A: Forest Plot for MACE Risk Factors ………………………………………………………………....45

Figure 4_B: MACE Risk Factors Forest Plot for All-Cause Mortality outcome…………………………….45

Figure 5: Forest Plot for All-Cause Mortality Risk Factors …………………………………………………...46

IX. References ..........................................................................................................................47

About this Master's Thesis

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School	Rollins School of Public Health
Department	Executive Masters of Public Health - MPH
Subfield / Discipline	Applied Epidemiology
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Health Sciences, Public Health Health Sciences, Medicine and Surgery
Keyword	Left Heart Catheterization Gensini Score Percutaneous Coronary Intervention Coronary artery disease Major Adverse Cardiovascular Events
Committee Chair / Thesis Advisor	Binongo, Jose, Emory University
Committee Members	Gold, Daniel, Emory University

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