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Risk Model for In-Hospital Mortality After PCI
Quick Takes
- This updated CathPCI in-hospital mortality risk score incorporates variables of extreme risk including frailty, cardiovascular instability, level of consciousness after cardiac arrest, and PCI after surgical consult.
- The risk score had excellent discrimination across different clinical and procedural risk cohorts.
- Incorporation of new variables helps standardize risk assessment and enhances prediction of risk of mortality following PCI.
Study Questions:
Can an updated clinical risk score better stratify patient risk and predict in-hospital mortality following percutaneous coronary intervention (PCI)?
Methods:
Data from 706,263 PCIs performed between July 2018 and June 2019 at 1,608 sites were used to develop and validate a new full and pre-catheterization model to predict in-hospital mortality, and a simplified bedside risk score. The sample was randomly split into a development cohort (70%, n = 495,005) and a validation cohort (30%, n = 211,258). The authors created 1,000 bootstrapped samples of the development cohort and used stepwise selection logistic regression on each sample. The final model included variables that were selected in ≥70% of the bootstrapped samples and those identified a priori due to clinical relevance.
Results:
In-hospital mortality following PCI varied based on clinical presentation. Procedural urgency, cardiovascular instability, and level of consciousness after cardiac arrest were most predictive of in-hospital mortality. The full model performed well, with excellent discrimination (C-index, 0.943) in the validation cohort and good calibration across different clinical and procedural risk cohorts. The median hospital risk-standardized mortality rate was 1.9% and ranged from 1.1%-3.3% (interquartile range, 1.7%-2.1%).
Conclusions:
The risk of mortality following PCI can be predicted in contemporary practice by incorporating variables that reflect clinical acuity. This model, which includes data previously not captured, is a valid instrument for risk stratification and for quality improvement efforts.
Perspective:
The National Cardiovascular Data Registry (NCDR) updated the CathPCI Registry in 2018 to include variables such as frailty, cardiovascular instability, level of consciousness after cardiac arrest, and PCI after surgical consult to better capture patient risk. This analysis looked to incorporate the added variables of extreme risk to improve risk standardization and more accurately predict risk of mortality after PCI. The bedside clinical risk score had excellent discrimination across different risk strata of patients and appears to enhance prior risk models. Given that the CathPCI mortality risk model is used for public reporting and determines payment, its ability to accurately assess and reflect case mix and risk is crucial.
Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias
Keywords: Calibration, Cardiovascular System, CathPCI Registry, Catheterization, Consciousness, Frail Elderly, Heart Arrest, Hospital Mortality, Percutaneous Coronary Intervention, Quality Improvement, Risk Assessment, Risk Factors, Secondary Prevention
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