Surgical Ineligibility and Mortality Among Patients With Unprotected Left Main or Multivessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention | Journal Scan
What is the association between surgical ineligibility documented in the medical record and long-term mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention (PCI)?
The authors identified surgical ineligibility among patients undergoing nonemergent PCI for unprotected left main or multivessel coronary artery disease at two academic medical centers from 2009-2012. Documentation of surgical ineligibility was assessed through review of the electronic medical record. Cox proportional hazard models were developed to adjust for known mortality risk factors and to compare long-term mortality in patients with and without documentation of surgical ineligibility.
The study population was comprised of 1,013 subjects with multivessel coronary artery disease, of whom 218 (22%) were deemed ineligible for coronary artery bypass graft surgery (CABG). The most common explicitly cited reasons for surgical ineligibility in the medical record were poor surgical targets (24%), advanced age (16%), and renal insufficiency (16%). After adjustment for known risk factors, surgical ineligibility was independently associated with an increased risk of in-hospital (odds ratio, 6.26; 95% confidence interval, 2.16-18.15; p < 0.001) and long-term mortality (hazard ratio, 2.98; 95% confidence interval, 1.88-4.72; p < 0.001) after PCI.
The authors concluded that documented surgical ineligibility is common and associated with significantly increased long-term mortality among patients undergoing PCI for unprotected left main or multivessel coronary disease.
This study highlights something that is clinically intuitive, but very important when viewed in the context of public reporting of outcome data and comparative effectiveness analysis. This finding (increased mortality among patients who are not surgical candidates) likely explains why randomized trials fail to demonstrate a survival difference between CABG and PCI (except in some key subgroups), while observational studies suggest marked superiority of CABG. This important predictor needs to be incorporated into the National Cardiovascular Data Registry (NCDR) CathPCI Registry to facilitate appropriate risk adjustment and help facilitate more balanced comparative effectiveness analysis.
Keywords: Academic Medical Centers, Coronary Artery Bypass, Coronary Artery Disease, Documentation, Electronic Health Records, Percutaneous Coronary Intervention, Renal Insufficiency, Risk Factors
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