Predictors of long-term survival after coronary artery bypass grafting surgery: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (the ASCERT study)

BACKGROUND

Most survival prediction models for coronary artery bypass grafting surgery are limited to in-hospital or 30-day end points. We estimate a long-term survival model using data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database and Centers for Medicare and Medicaid Services.

METHODS AND RESULTS

The final study cohort included 348 341 isolated coronary artery bypass grafting patients aged ≥65 years, discharged between January 1, 2002, and December 31, 2007, from 917 Society of Thoracic Surgeons-participating hospitals, randomly divided into training (n=174 506) and validation (n=173 835) samples. Through linkage with Centers for Medicare and Medicaid Services claims data, we ascertained vital status from date of surgery through December 31, 2008 (1- to 6-year follow-up). Because the proportional hazards assumption was violated, we fit 4 Cox regression models conditional on being alive at the beginning of the following intervals: 0 to 30 days, 31 to 180 days, 181 days to 2 years, and >2 years. Kaplan-Meier-estimated mortality was 3.2% at 30 days, 6.4% at 180 days, 8.1% at 1 year, and 23.3% at 3 years of follow-up. Harrell's C statistic for predicting overall survival time was 0.732. Some risk factors (eg, emergency status, shock, reoperation) were strong predictors of short-term outcome but, for early survivors, became nonsignificant within 2 years. The adverse impact of some other risk factors (eg, dialysis-dependent renal failure, insulin-dependent diabetes mellitus) continued to increase.

CONCLUSIONS

Using clinical registry data and longitudinal claims data, we developed a long-term survival prediction model for isolated coronary artery bypass grafting. This provides valuable information for shared decision making, comparative effectiveness research, quality improvement, and provider profiling.

Abstract 6: Temporal Shifts in Antithrombotic Therapy Help Explain Reduction in Bleeding Complications Among Patients Undergoing Percutaneous Coronary Intervention: Results from an NCDR® Report

Background Though studies suggest post-PCI bleeding has decreased over time, the factors associated with this temporal reduction remain unclear.

Methods Using the CathPCI Registry®, we examined temporal trends in bleeding between 2005-2009 in elective PCI (E-PCI) (n=599,524), UA/NSTEMI (n=836,103), and STEMI (n=267,632). We quantified the linear time trend in bleeding using three sequential logistic regression models: (Model 1) Clinical factors associated with PCI bleeding; (Model 2) Model 1 + vascular access strategies(femoral vs. radial, closure devices); (Model 3) Model 2 + anticoagulation treatments (anticoagulation ± GP 2b/3a). Changes in the adj. OR for time trend were then compared. Table illustrates changes in expected annual bleeding events using 2005 event rates as reference (n=1375 bleeds in E-PCI, n=3327 in UA/NSTEMI, n=1978 in STEMI).

Results Between 2005-2009, there was an approximate 20% decline in PCI bleeding: absolute crude change for E-PCI (1.4% to 1.1%), for UA/NSTEMI (2.3% to 1.8%), for STEMI (4.9% to 4.5%). In this period, vascular access via radial remained low (<3%) and closure devices use was steady (45-50%). In contrast, bivalirudin use increased from 17% to 30%, while heparin + GP2b/3a decreased from 41% to 28%. After adjusting for clinical variables, there was a 6-8% per year reduction in adj OR of bleeding for E-PCI & UA/NSTEMI (Table). While there was only a small reduction in bleeds per year after adjusting for changes in vascular access strategies, adjusting for antithrombotic strategies accounted for nearly half of the temporal annual reduction in bleeding (Table): from 97 to 48 expected bleeds per year for E-PCI, 164 to 95 in UA/NSTEMI, and 49 to 23 in STEMI.

Conclusion There has been a modest temporal reduction in post-PCI risk of bleeding. Nearly half of this reduction can be attributable to changes in antithrombotic choices. Adoption of the radial approach, combined with pharmacological strategies, may further reduce bleeding.

Elective PCI Model Unstable Angina/NSTEMI STEMI OR p-value Estimated reduction bleeding events per year OR p-value Estimated reduction bleeding events per year OR p-value Estimated reduction bleeding events per year Model 1 0.92 (0.90-0.95) <0.001 97 0.94 (0.92-0.96) <0.001 164 0.98 (0.95-1.00) 0.088 49 Model 3 0.96 (0.93-0.99) * 0.002 48 0.97 (0.95-0.99) * 0.012 95 0.99 (0.96-1.02) * 0.525 23 *

Appropriateness of percutaneous coronary intervention

CONTEXT

Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown.

OBJECTIVE

To assess the appropriateness of PCI in the United States.

DESIGN, SETTING, AND PATIENTS

Multicenter, prospective study of patients within the National Cardiovascular Data Registry undergoing PCI between July 1, 2009, and September 30, 2010, at 1091 US hospitals. The appropriateness of PCI was adjudicated using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication.

MAIN OUTCOME MEASURES

Proportion of acute and nonacute PCIs classified as appropriate, uncertain, or inappropriate; extent of hospital-level variation in inappropriate procedures.

RESULTS

Of 500,154 PCIs, 355,417 (71.1%) were for acute indications (ST-segment elevation myocardial infarction, 103,245 [20.6%]; non-ST-segment elevation myocardial infarction, 105,708 [21.1%]; high-risk unstable angina, 146,464 [29.3%]), and 144,737 (28.9%) for nonacute indications. For acute indications, 350,469 PCIs (98.6%) were classified as appropriate, 1055 (0.3%) as uncertain, and 3893 (1.1%) as inappropriate. For nonacute indications, 72,911 PCIs (50.4%) were classified as appropriate, 54,988 (38.0%) as uncertain, and 16,838 (11.6%) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), or suboptimal (≤1 medication) antianginal therapy (95.8%). Furthermore, although variation in the proportion of inappropriate PCI across hospitals was minimal for acute procedures, there was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%-16.7%).

CONCLUSIONS

In this large contemporary US cohort, nearly all acute PCIs were classified as appropriate. For nonacute indications, however, 12% were classified as inappropriate, with substantial variation across hospitals.

Acceptance, panic, and partial recovery the pattern of usage of drug-eluting stents after introduction in the U.S. (a report from the American College of Cardiology/National Cardiovascular Data Registry)

OBJECTIVES

Review the use of drug-eluting stents (DES) to evaluate changes in use.

BACKGROUND

The DES were approved after several small studies in carefully selected patients showed dramatic reduction in in-stent restenosis. The DES were then rapidly adopted into routine practice. In 2006, 3 years after introduction, serious concerns regarding long-term safety were raised.

METHODS

We queried the American College of Cardiology/National Cardiovascular Data Registry (ACC/NCDR) CathPCI Registry. The percentage of DES used through mid-2009 was reviewed overall and in subgroups of patients categorized by lesion type, clinical factors, insurance, and hospital characteristics. Multivariable logistic models relating these covariates to DES usage were constructed for 3 relevant time intervals.

RESULTS

A total of 2,247,647 coronary stent procedures were analyzed. By 2005 over 90% of first stents placed were DES. Safety concerns arising in 2006 reduced DES use to 64% of first stent placed. After publication of salutary outcomes data in 2008, usage increased to 76% by mid-2009. The logistic models demonstrated decreased likelihood of DES usage in patients with: 1) ST-segment elevation myocardial infarctions; and 2) no medical insurance. The DES usage increased for in-stent restenosis. Hospital characteristics were not associated with significant differences in DES usage.

CONCLUSIONS

There was rapid adoption of DES into U.S. clinical practice. Concern for late stent thrombosis in 2006 significantly altered DES use with reductions seen in subgroups at risk for thrombosis and patients with no insurance. These rapid cyclic changes after DES introduction reinforce the need for continuous, timely reporting of outcomes data after the introduction of new technologies.

The neurointerventional procedure room of the future: predicting likely innovations in design and function

The Multispecialty Occupational Health Group, as part of their work, have considered likely characteristics of the neurointerventional surgery operating room of tomorrow. Such rooms will be distinguished by certain architectural features and markedly increased information technology features. The novel architectural features will include system proximities, such as embedding the procedure room next to traditional operating rooms, anesthesia recovery units, intensive care units or the emergency department. Novel features will likely also include distinct, contained, open sided control areas for technical and medical staff, integrated modular multimodality capability for non-ionizing extravascular and endovascular imaging and therapeutic tools, and various additional described distinct features. Information technology features will permit importation of multiple imaging datastreams, quality and performance monitoring, measuring and exportation, and utilization trajectory matched automated inventory systems. Additional needs will likely include streaming imaging and physiologic information channels, in selected instances supplemental cross sectional and metabolic imaging equipment, robotic intermediaries and more formally designated stations for datastream and scrub technologists.

Contemporary mortality risk prediction for percutaneous coronary intervention: results from 588,398 procedures in the National Cardiovascular Data Registry

OBJECTIVES

We sought to create contemporary models for predicting mortality risk following percutaneous coronary intervention (PCI).

BACKGROUND

There is a need to identify PCI risk factors and accurately quantify procedural risks to facilitate comparative effectiveness research, provider comparisons, and informed patient decision making.

METHODS

Data from 181,775 procedures performed from January 2004 to March 2006 were used to develop risk models based on pre-procedural and/or angiographic factors using logistic regression. These models were independently evaluated in 2 validation cohorts: contemporary (n = 121,183, January 2004 to March 2006) and prospective (n = 285,440, March 2006 to March 2007).

RESULTS

Overall, PCI in-hospital mortality was 1.27%, ranging from 0.65% in elective PCI to 4.81% in ST-segment elevation myocardial infarction patients. Multiple pre-procedural clinical factors were significantly associated with in-hospital mortality. Angiographic variables provided only modest incremental information to pre-procedural risk assessments. The overall National Cardiovascular Data Registry (NCDR) model, as well as a simplified NCDR risk score (based on 8 key pre-procedure factors), had excellent discrimination (c-index: 0.93 and 0.91, respectively). Discrimination and calibration of both risk tools were retained among specific patient subgroups, in the validation samples, and when used to estimate 30-day mortality rates among Medicare patients.

CONCLUSIONS

Risks for early mortality following PCI can be accurately predicted in contemporary practice. Incorporation of such risk tools should facilitate research, clinical decisions, and policy applications.

Incidence and predictors of stroke associated with percutaneous coronary intervention

Stroke is a serious complication of percutaneous coronary intervention (PCI). Clinical characteristics associated with this complication have not been well defined. Data were analyzed from the National Cardiovascular Data Registry. All patients undergoing PCI from January 1, 2004, to March 30, 2007, were included in the analysis (n = 706,782). Stroke is defined in the National Cardiovascular Data Registry as a central neurologic deficit persisting >72 hours with onset starting anytime in the cardiac catheterization laboratory until the time of hospital discharge. Periprocedural stroke developed in 0.22% of patients (n = 1,540). Patients who developed a stroke had a greater prevalence of concomitant medical illnesses and were more likely to present with an acute coronary syndrome. Patients with a stroke had a greater percentage of high-risk coronary lesions and worse PCI angiographic results. In multivariable analysis, known cerebrovascular disease, older age, acute coronary syndromes (unstable angina, ST- and non-ST-elevation myocardial infarction), and use of an intra-aortic balloon pump were factors most strongly associated with stroke. In-hospital mortality was 30% for patients who developed a stroke compared with 1% for those without stroke. In conclusion, stroke developing in association with PCI is rare but a devastating complication. Older patients and those with known cerebrovascular disease and acute coronary syndromes appear to be at the highest risk of stroke. The strong association of in-hospital stroke after PCI with acute coronary syndromes is noteworthy.

Temporal changes in the use of drug-eluting stents for patients with non-ST-Segment-elevation myocardial infarction undergoing percutaneous coronary intervention from 2006 to 2008: results from the can rapid risk stratification of unstable angina patients supress ADverse outcomes with early implementation of the ACC/AHA guidelines (CRUSADE) and acute coronary treatment and intervention outcomes network-get with the guidelines (ACTION-GWTG) registries

BACKGROUND

The risks of late stent thrombosis with drug-eluting stents (DES) were intensely debated after the presentation of a number of studies highlighting this issue in September 2006. We evaluated trends in the use of DES for patients with non-ST-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) from 2006 to 2008.

METHODS AND RESULTS

Temporal patterns of DES use were examined among non-ST-elevation myocardial infarction patients in the Can Rapid risk stratification of Unstable angina patients Supress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE; January 2006 to December 2006) and Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (ACTION-GWTG; January 2007 to June 2008) registries to determine how practice patterns changed for patients with acute myocardial infarction undergoing PCI. Among the 54 662 patients analyzed, the percentage of patients undergoing PCI by quarter varied from 54% to 58% during the analysis time period. More than 90% of patients undergoing PCI received a DES in the first 3 quarters of 2006 before the public debate about the risks of DES began. Thereafter, the use of DES for PCI patients declined during the fourth quarter of 2006 through the first quarter of 2007 (82% to 67%), gradually declined during quarters 2 to 4 of 2007 (63% to 63% to 59%) but then slightly increased from the first to second quarter of 2008 (58% to 60%). Hospital characteristics did not seem to correlate with temporal changes in DES use, but by the last 2 quarters of the study period, patient characteristics such as white race, hypertension, diabetes mellitus, and private or managed care insurance were more common among patients who received a DES compared with the beginning 2 quarters of the study period.

CONCLUSIONS

These findings highlight how rapidly treatment decisions in contemporary practice can be affected by public debate related to scientific presentations and publications.

Survival benefit from early revascularization in elderly patients with cardiogenic shock after acute myocardial infarction: a cohort study

OBJECTIVES

To assess if early revascularization offers any survival benefit in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) who are > or = 75 years of age.

BACKGROUND

CS after AMI continues to pose formidable therapeutic challenges in elderly patients.

METHODS

We conducted survival analyses of 310 consecutive subjects (including 80 patients > or = 75 years of age) who developed cardiogenic shock after AMI at two study centers - Rush University Medical Center and the John H. Stroger Jr. Hospital of Cook County (both in Chicago, Illinois). The data were collected over a 6-year period. Where appropriate, we used Kaplan-Meier survival plots, multivariate Cox proportional hazards modeling, stepwise multivariate Poisson regression analyses and unconditional logistic regression analysis.

RESULTS

Early revascularization was associated with a statistically significant survival benefit both in patients < 75 years of age (relative hazard 0.40, 95% confidence interval [CI] 0.28-0.59; p < 0.001), as well as in patients > or = 75 years of age (relative hazard 0.56, 95% CI 0.32-0.99; p = 0.049). This benefit remained significant even after adjusting for the simultaneous effects of several putative confounders. In patients > or = 75 years of age, this survival benefit was evident very early and was sustained all through the period of follow up of the cohort.

CONCLUSIONS

These retrospective data suggest a significant survival benefit of early revascularization in elderly patients > or = 75 years of age developing CS after AMI, albeit less as compared to those aged < 75 years.