Prognosis of patients with triple vessel coronary artery disease
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Prognosis in Triple Vessel Coronary Artery Disease: Survival and Mortality Risk
Patients with triple vessel coronary artery disease (TVD) generally face a poor prognosis, especially when not treated with revascularization. Five-year survival rates for these patients are significantly lower compared to those with single or double vessel disease, with reported survival rates around 55–65% for TVD, compared to 92% for single vessel and 65% for double vessel disease 15. Cardiac mortality is high, and the risk increases further in the presence of left ventricular dysfunction, heart failure, or severe angina 15.
Key Predictors of Poor Outcomes in Triple Vessel Disease
Several clinical and laboratory factors have been identified as independent predictors of worse outcomes in TVD:
- Heart Failure and Angina Severity: The presence of heart failure, resting angina, and a higher cardiothoracic ratio are strongly associated with increased cardiac mortality .
- Impaired Left Ventricular Function: Lower ejection fraction is linked to higher risk of cardiac death, especially in patients with a history of myocardial infarction .
- Coronary Occlusion Patterns: Coronary occlusion opposite the site of previous myocardial infarction and the presence of two-vessel occlusion further worsen prognosis .
- Older Age: Patients aged 65 years or older have a significantly higher risk of adverse outcomes .
Laboratory Markers and Prognosis in TVD
- White Blood Cell Count: Elevated total white blood cell count, especially increased monocytes and eosinophils, and decreased lymphocytes, are independent predictors of long-term mortality and major adverse cardiovascular and cerebrovascular events (MACCE) in TVD .
- Serum Albumin: Hypoalbuminemia (albumin <4.0 g/dL) is a strong independent predictor of all-cause death and MACCE. Adding albumin levels to established risk scores (like SYNTAX) improves the prediction of mortality in TVD patients .
Impact of Revascularization Strategies
Complete revascularization in TVD, especially in high-risk groups such as out-of-hospital cardiac arrest survivors, is associated with better neurologically intact survival compared to incomplete or no immediate revascularization . This suggests that aggressive intervention may improve outcomes in selected patients.
Anatomical and Imaging Predictors
- Right Coronary Dominance: Patients with right coronary dominance are more likely to have TVD and may be at higher risk for adverse events, indicating the need for closer monitoring and preventive strategies .
- Carotid Intima-Media Thickness (CIMT): Increased CIMT is significantly correlated with the presence of TVD, especially in older patients and females, suggesting its utility as a non-invasive risk stratification tool .
- Choroidal Vascularity Index (CVI): Lower CVI values are associated with TVD, and may help indicate severe coronary disease, although it is less sensitive for early detection .
Special Populations
- Younger Patients with Acute Coronary Syndrome: TVD can occur even in patients under 40 presenting with acute coronary syndrome, with a frequency of about 23%, highlighting the need for vigilance in younger populations .
Conclusion
Triple vessel coronary artery disease is associated with a poor long-term prognosis, particularly in the absence of revascularization and in the presence of heart failure, impaired ventricular function, and certain laboratory abnormalities. Risk stratification using clinical, laboratory, and imaging markers can help identify high-risk patients who may benefit from more aggressive management and closer follow-up. Early intervention and comprehensive risk assessment remain crucial for improving outcomes in this high-risk group.
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