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Characteristics and Outcomes of Patients Undergoing Coronary Revascularization
Study Questions:
What are contemporary trends in patient characteristics and outcomes after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)?
Methods:
This is a retrospective cohort study using the Nationwide Inpatient Sample database of hospitalizations of patients 18 years and older who underwent coronary revascularization with PCI or CABG between January 2003 and December 2016. Patients who underwent PCI were stratified by indication as ST-segment elevation myocardial infarction (STEMI), non–ST-segment elevation MI (NSTEMI), and unstable angina or stable ischemic heart disease (UA-SIHD). Patients who underwent CABG were stratified by indication as acute MI (AMI) and UA-SIHD. The time period was divided into three eras (2003-2007, 2008-2012, and 2013-2016). Trends in clinical risk profile and crude and adjusted in-hospital mortality were analyzed.
Results:
Of 12,062,081 revascularization hospitalizations identified, 8,687,338 were for PCI and 3,374,743 were for CABG. Annual volume for PCI decreased from 366 to 180 per 100,000 US adults, while annual volume for CABG decreased from 159 to 82 per 100,000 US adults. For both the PCI and CABG groups, over time, patients trended towards being older, male, and nonwhite and having more atherosclerotic and non-atherosclerotic risk factors, higher Elixhauser comorbidity index, and lower socioeconomic status. Comparing the 2013-2016 to 2003-2007 eras, PCI was performed more for STEMI (14.0% vs. 7.2%, p < 0.001) and NSTEMI (39.1% vs. 15.6%, p < 0.001) rather than UA-SIHD, with an increase in patients with cardiogenic shock, needing mechanical circulatory support, and having chronic total occlusion. CABG was performed more for AMI (28.2% vs. 19.6%, p < 0.001) rather than UA-SIHD, with less off-pump CABG and more use of arterial conduit. Risk-adjusted mortality increased slightly after PCI for STEMI (4.9% to 5.3%) and UA-SIHD (0.8% to 1.0%) (p < 0.001 for trend for both), but was stable for NSTEMI. Risk-adjusted mortality decreased after CABG and isolated CABG for AMI (5.6% to 3.4%; 4.8% to 3.0%, respectively) and UA-SIHD (2.8% to 1.7%; 2.1% to 1.2%, respectively) (p < 0.001 for all).
Conclusions:
There have been significant changes in the risk profile of patients undergoing PCI and CABG, procedural volume, and outcomes from 2003-2016.
Perspective:
This analysis is limited in that it can only examine administrative data and in-hospital outcomes. (Of note, operative mortality after CABG is generally higher than in-hospital mortality and can be found in reports of the Society of Thoracic Surgeons Adult Cardiac Surgery Database.) Regardless, there are several important implications of the study findings. First, volume of PCI and CABG is not a zero-sum game. That is, decline in CABG volume does not necessarily imply increase in PCI volume, and vice versa. Second, over time, patients undergoing both procedures have become sicker, with increased comorbidities, more difficult anatomy, and likely increased procedural risk. Third, as trials such as the ISCHEMIA trial highlight, medical management, PCI, and CABG are complementary, not competing, therapies for coronary artery disease. These further support the need for heart team evaluation of these patients, where all options are on the table, procedural risk can be shared, and benefit for the patient is enhanced.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease
Keywords: Acute Coronary Syndrome, Angina, Unstable, Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Coronary Occlusion, Hospital Mortality, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk Factors, Shock, Cardiogenic
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