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Revascularization in Asymptomatic Heart Disease
Study Questions:
What is the variation in revascularization of asymptomatic patients with stable ischemic heart disease (SIHD), predictors of such variation, and association with clinical outcomes?
Methods:
The investigators performed a retrospective observational cohort study using population-based data from Ontario, Canada in patients with asymptomatic SIHD and obstructive coronary artery disease. The cohort was divided based on treatment strategy: revascularization or medical therapy. Hospitals were allocated into tertiles of their revascularization ratio. Outcomes included death and nonfatal myocardial infarction. Hierarchical logistic regression was used to assess the predictors of revascularization, with median odds ratios (MORs) used to quantify variation. Proportional hazards models were used to determine the association between management strategy and outcomes.
Results:
The cohort included 9,897 patients: 47% treated with medical therapy and 53% with revascularization. Between hospitals, two-fold variation existed in the ratio of revascularized to medically treated patients. However, the variation across hospitals was not explained by patient, physician, or hospital factors (MOR in null model, 1.25; MOR in full model, 1.31). Revascularization was associated with a hazard ratio [HR] of 0.81 (95% confidence interval [CI], 0.69–0.96) for death and HR of 0.58 (95% CI, 0.46–0.73) for myocardial infarction with this benefit consistent across tertiles of revascularization ratio.
Conclusions:
The authors concluded that despite variation in revascularization practice, a clinical benefit was observed with revascularization that was consistent across hospitals.
Perspective:
This study reports a two-fold institutional variation in revascularization of asymptomatic patients with obstructive coronary artery disease. The strongest predictor of revascularization was coronary anatomy; however, after accounting for patient, physician, and hospital factors, substantial variation in hospital revascularization practices remained. Despite this variation, there was an improvement in clinical outcomes associated with revascularization that was consistent across tertiles of hospitals. Given the potential for significant selection bias regarding the clinical decision for angiography, these results should be considered hypothesis generating and not practice-changing. The ongoing ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches; NCT01471522) trial will offer more robust clinical insights regarding optimal management of this patient population.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Angiography, Coronary Artery Disease, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Outcome Assessment, Health Care, Secondary Prevention
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