Trend in percutaneous coronary intervention volume following the COURAGE and BARI-2D trials

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Clinical and Economic Burden of Percutaneous Coronary Intervention in Hospitalized Young Adults in the United States, 2004-2018

BACKGROUND

The clinical and economic burden of percutaneous coronary intervention (PCI) in young adults (<45 years) is understudied.

METHODS AND RESULTS

We used the National Inpatient Sample database between 2004 and 2018 to study trends in PCI volume, in-hospital mortality, length of stay (LOS), and health care expenditure among adults aged 18- 44 years who underwent PCI. The data were weighted to explore national estimates of the entire US hospitalized population. We identified 558,611 PCI cases, equivalent to 31.4 per 1,000,000 person-years; 25.4% were women, and 69.5% were White adults. Overall, annual PCI volume significantly decreased from 41.6 per 100,000 in 2004 to 21.9 per 100,000 in 2018, mainly due to 83% volume reduction in non-myocardial infarction (MI) cases. The prevalence of cardiometabolic comorbidities, smoking, and drug abuse increased. Overall, in-hospital mortality was 0.87%; women had higher mortality than men (1.12% vs. 0.78%; P=0.01). The crude and risk-adjusted in-hospital mortality significantly increased between 2004 and 2018. Women, STEMI, NSTEMI, drug abuse, heart failure, peripheral vascular disease, and renal failure were associated with higher odds of in-hospital mortality. Inflation-adjusted cost significantly increased over time ($21,567 to $24,173).

CONCLUSION

We noted reduction in PCI volumes but increasing mortality and clinical comorbidities among young patients undergoing PCI. Demographic disparities existed with women having higher in-hospital mortality than men.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

ISCHEMIA Trial and the Significance of MI

During the past decade, the treatment of choice for chronic coronary syndromes (CCS) has been a contentious issue. Whether revascularisation, either percutaneous or surgical, or optimal medical therapy, offers better prognosis in terms of mortality, MI, and symptom relief, has yet to be confirmed. The long-awaited and recently published International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial randomised more than 5,000 patients into a revascularisation plus optimal medical therapy group and an optimal medical therapy alone group. The authors analyse the trial, with particular emphasis on the incidence of MI. They propose a patient-centred approach to incorporate the results of the ISCHEMIA trial into daily practice and determine the best treatment strategy for patients with CCS.

Coronary Disease Surveillance in the Community: Angiography and Revascularization

Background Temporal declines in cardiac stress tests results, coronary revascularization, and cardiovascular mortality have suggested a decline in the population burden of coronary disease until the 2000s. However, recent data indicate these favorable trends could be ending. We aimed to assess the evolution of the population burden of coronary disease in the community by examining trends in angiography and revascularization. Methods and Results We analyzed age- and sex-adjusted trends from all coronary angiographic diagnostic procedures and revascularizations performed in Olmsted County, MN from 2000 to 2018. A total of 12 981 invasive angiograms were performed among 9049 individuals (64% men; 55% aged ≥65 years). Adjusted angiography rates decreased by 30% (95% CI, 25%-34%) between 2000 and 2009 and leveled off thereafter. Including computed tomography, angiography uncovered an increase in angiography use in recent years (risk ratio=1.15 [95% CI, 1.07-1.23] for 2018 versus 2014) and a decline in the prevalence of anatomic CAD from 2000 to 2018. CAD severity declined substantially from 2000 to 2009, followed by a plateau. Among 6570 revascularizations (72% men; 57% aged ≥65 years), 77% were percutaneous coronary interventions and 23% coronary artery bypass graft surgeries. The adjusted revascularization rates declined by 34% (95% CI, 27%-39%) from 2000 to 2009, followed by a plateau (risk ratio=1.10 [95% CI, 1.00-1.22]). Conclusions Between 2000 and 2018 in the community, coronary angiography use declined initially, leveled off, and then increased. Trends in CAD severity and revascularization use decreased then plateaued. The most recent trends are concerning as they suggest the burden of coronary disease is no longer declining. This warrants reinvigorated primary prevention and population surveillance.

Appropriateness of Percutaneous Coronary Interventions in Patients With Stable Coronary Artery Disease in US Department of Veterans Affairs Hospitals From 2013 to 2015

IMPORTANCE

In hospitals outside of the US Department of Veterans Affairs (VA) system, 1 in 10 percutaneous coronary interventions (PCIs) for stable coronary artery disease is considered rarely appropriate by the appropriate use criteria, with variation across hospitals. The appropriateness of PCIs in VA hospitals has not been documented.

OBJECTIVE

To characterize the appropriateness of PCIs in VA hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients with stable coronary artery disease undergoing elective PCI from November 1, 2013, to October 31, 2015, within the VA Clinical Assessment, Reporting, and Tracking Program, an operational program that includes 59 VA hospitals. Data were analyzed from March 1, 2019, to August 8, 2019.

EXPOSURES

Elective PCI at a VA hospital.

MAIN OUTCOMES AND MEASURES

Proportion of PCIs classified as appropriate, may be appropriate, or rarely appropriate; extent of hospital-level variation in rarely appropriate PCIs using criteria issued by cardiovascular professional societies in 2012. The extent of hospital-level variation in rates of rarely appropriate PCI was characterized using hospital proportions and random-effect logistic regression.

RESULTS

Among 2611 patients undergoing elective PCI (mean [SD] age, 66.3 [7.6] years; 2577 [98.7%] men) at 59 hospitals, a total of 778 PCIs (29.8%) were classified as appropriate, 1561 PCIs (59.8%) were classified as may be appropriate, and 272 PCIs (10.4%) were classified as rarely appropriate. Rarely appropriate PCIs were more commonly performed in patients who had low-risk stress test findings (220 patients [89.1%]), who were taking no (100 patients [36.8%]) or 1 (167 patients [61.4%]) antianginal medication, or who had 1 coronary artery stenosis (185 patients [68.0%]). The unadjusted hospital-level rates of rarely appropriate PCIs ranged from 0% to 28.6%, with a median (interquartile range) of 9.7% (6.3%-13.9%). Random-effect models yielded an estimated median (interquartile range) rate of rarely appropriate PCI of 10.4% (8.7%-12.3%).

CONCLUSIONS AND RELEVANCE

These findings suggest that in VA practice, most PCIs for stable coronary artery disease were classified as appropriate or may be appropriate. However, 1 in 10 PCIs was classified as rarely appropriate, with variation across VA hospitals. Efforts to improve patient selection are needed.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Outcomes of Percutaneous Coronary Intervention in Atrial Fibrillation Patients Presenting With Acute Myocardial Infarction: Analysis of Nationwide Inpatient Sample Database

BACKGROUND

Atrial fibrillation (AF) is common in patients presenting with myocardial infarction (MI). Percutaneous coronary intervention (PCI) has been shown to improve cardiovascular outcomes in MI. However, outcomes of PCI in AF patients presenting with MI remains largely unknown.

METHODS

We analyzed the Nationwide Inpatient Sample (NIS) database to calculate the age adjusted mortality rate for PCI in AF patients presenting with MI between 2002 and 2011, in adults over 40 years of age. This was then compared to the mortality rate for PCI in non-AF patients with MI. Specific ICD-9-CM codes were used to identify patients and outcomes.

RESULTS

Of 3,226,405 PCIs done during the study period, 472,609 (14.6%) PCIs were done on AF patients of which 137,870 PCIs were for MI. About 60% of these patients were male. Patients with AF were older (71.3 ± 10.6 years). Overall the number of PCIs shows a declining trend from 2002 to 2011, but for MI patients the number of PCIs appears stable over the years. The age adjusted in-hospital mortality following PCI in MI was significantly higher in AF group compared to the non-AF group (190.24 ± 17.21vs 109.08 ± 5.89 per 100,000; P < 0.01). This trend was seen during the entire study period.

CONCLUSIONS

AF is prevalent in MI patients undergoing PCI. AF is associated with increased mortality following PCI for acute MI. AF is not a benign arrhythmia in MI patients and close attention is warranted in these patients to improve mortality.

Advances in Management of Stable Coronary Artery Disease: the Role of Revascularization?

PURPOSE OF REVIEW

Coronary artery disease remains the most common cause of death worldwide. In patients with biomarker-positive acute coronary syndrome, the combination of guideline-directed medical therapy with routine revascularization is associated with improved outcomes. However, the role of routine revascularization in stable ischemic heart disease, in addition to medical therapy, remains a matter of debate. In this review, we aimed to describe the role of revascularization in stable ischemic heart disease.

RECENT FINDINGS

Revascularization is indicated in patients with stable ischemic heart disease and progressive or refractory symptoms, despite medical management. When guided by ischemia presence, revascularization has failed to show survival benefit, compared with medical therapy alone in multiple clinical trials. On the other hand, revascularization guided by coronary lesion severity, assessed by FFR or iFR, has been shown to offer survival benefit and improvement in symptom severity. PCI-revascularization of unprotected left main disease is feasible with comparable to surgical approach outcomes. Clinical decision to perform revascularization in stable ischemic heart disease necessitates a heart team approach, and no simple algorithm can guide this process. Further studies are required to assess the benefit of routine revascularization, in combination to medical therapy, in this population.

Antithromboembolic Strategies for Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

We set out to synthesize available data on antithrombotic strategies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), with a focus on triple antithrombotic therapy (triple therapy [TT]; dual antiplatelet therapy plus an anticoagulant) versus dual therapy (DT; one antiplatelet agent and an anticoagulant). We searched OVID MEDLINE and PubMed from January 2005 to September 2017 using the search terms oral anticoagulant, triple therapy, dual therapy, acute coronary syndrome, percutaneous coronary intervention, and atrial fibrillation (limited to randomized controlled trials, observational studies, English language, minimum 6-12 months of follow-up, minimum 100 human patients). We excluded surveys, literature reviews, articles not directly related to TT versus DT, incomplete studies, and short-term in-hospital studies. All eligible studies were reviewed to evaluate possible antithrombotic management strategies for patients with AF undergoing PCI. Extracted studies were categorized according to the specific anticoagulant (vitamin K antagonist vs. direct-acting oral anticoagulant) and P2Y₁₂ inhibitor used. Each category review was followed by a discussion providing insight into the quality of evidence and implications for practice. We found that the risk of bleeding with TT was higher than with DT, without demonstrated added benefit of reducing major adverse cardiovascular events. TT use should be minimized in patients with high bleeding risk, and patient-specific factors should be critically analyzed to select appropriate antiplatelet and anticoagulant agents.

Trends in proportions of hospitals and operators not meeting minimum percutaneous coronary intervention volume standards in Taiwan, 2001-2013

OBJECTIVE

To examine trends in proportions of hospitals and operators not meeting the minimum percutaneous coronary intervention (PCI) volume standards in Taiwan during 2001-2013.

BACKGROUND

The 2013 Clinical Competence Statement recommends that operators perform a minimum of ≥50 PCIs annually (averaged over a 2-year period) in hospitals conducting ≥200 PCIs annually.

METHODS

Taiwan National Health Insurance claims data from 2001 to 2013 are used to determine the annual numbers of PCIs performed by each hospital and operator.

RESULTS

The percentage of hospitals conducting annual PCI volumes of <200 decreased from 57% (26/46) in 2001 to 39% (29/74) in 2007 and 33% (33/91) in 2013; the percentage of operators conducting PCI volumes <50 annually remained relatively constant at 60% (146/243) in 2001, 60% (270/452) in 2007, and 58% (354/611) in 2013; and the percentage of operators conducting low volumes (<50) in low-volume hospitals (<200) decreased from 24% (57/243) in 2001 to 15% (66/452) in 2007 and 12% (76/611) in 2013.

CONCLUSIONS

Approximately one-third of hospitals and three-fifths of operators in Taiwan failed to meet minimum PCI volume standards. Further research examining patient outcomes from PCIs performed by low-volume hospitals and operators is recommended.

Optimal achieved blood pressure for patients with stable coronary artery disease

We aimed to investigate the ideal achieved blood pressure (BP) in ethnic Chinese patients with stable coronary artery disease (CAD) in Taiwan. A total of 2,045 patients (age 63.5 ± 11.9 years, 1,722 male [84.2%]) with stable CAD who had undergone percutaneous coronary interventions were enrolled. The achieved systolic BP was 130.6 ± 17.7 mmHg and diastolic BP was 74.9 ± 12.0 mmHg. In 12 months, patients with systolic BP < 120 mmHg and systolic BP ≥ 160 mmHg had increased risk of total cardiovascular events when compared to those with systolic BP 120-139 mmHg. In 24 months, patients with systolic BP < 120 mmHg and systolic BP ≥ 160 mmHg had increased risk of total cardiovascular events when compared to those with systolic BP 120-139 mmHg; patients with diastolic BP < 70 mmHg had increased risk of total cardiovascular events when compared to those with diastolic BP 70-79 mmHg. In conclusion, systolic BP < 120 mmHg and ≥160 mmHg or diastolic BP < 70 mmHg is associated with increased cardiovascular events, supporting that the optimal BP control should also be justified for stable CAD in non-western cohorts.

Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications - a nationwide population-based study

Background

The volume and percentage of percutaneous coronary interventions (PCIs) performed for nonacute indications have declined in the United States since 2007. However, little is known if similar trends occurred in Taiwan.

Methods

We used data from Taiwan National Health Insurance inpatient claims to examine the regional and hospital variations in the extent of decline in the percentage of nonacute indication PCIs from 2007 to 2012.

Results

The volume of total PCIs persistently increased from 29,032 in 2007 to 35,811 in 2010 and 37,426 in 2012. However, the volume of nonacute indication PCIs first increased from 7916 in 2007 to 9143 in 2009 and then decreased to 8666 in 2012. The percentage of nonacute indication PCIs steadily decreased from 27% in 2007 to 26% in 2009 and then to 23% in 2012, a − 15% change. The extent of decline was largest in the North region (from 27% to 21%, a − 22% change) and least in Kaopin region (from 20% to 18%, a − 13% change). Of the 71 hospitals studied, 14 did not show a decreasing trend. Five of the 14 hospitals even showed an increasing trend, with a percentage change >10% between 2007 and 2012. In 2012, 6 hospitals had a nonacute indication PCI percentage >35%.

Conclusions

In Taiwan, four-fifths of the hospitals showed a decline in the percentage of nonacute indication PCIs from 2007 to 2012. It is plausible that Taiwanese cardiologists would have been influenced by the recommendations of crucial US trials and guidelines.

Trends in Coronary Revascularization and Ischemic Heart Disease-Related Mortality in Israel

BACKGROUND

We investigated national trends in volume and outcomes of percutaneous coronary angioplasty (PCI), coronary artery bypass grafting (CABG), and ischemic heart disease-related mortality in Israel.

METHODS AND RESULTS

Using International Classification of Diseases 9th and 10th revision codes, we linked 5 Israeli national databases, including the Israel Center for Disease Control National PCI and CABG Registries, the Ministry of Health Hospitalization Report, the Center of Bureau of Statistics, and the Ministry of Interior Mortality Report, to assess the annual PCI and CABG volume, procedural mortality, comorbidities, and ischemic heart disease-related mortality between 2002 and 2014. Trends over time were analyzed using linear regression, assuming a Poisson distribution. A total of 298 390 revascularization procedures (PCI: 255 724, CABG: 42 666) were performed during the study period. PCI volume increased by 9% from 2002 to 2008 (387.4/100 000 to 423.2/100 000), steadily decreasing by 10.5% to 378.5/100 000 in 2014 (P=0.70 for the trend). CABG volume decreased by 59% (109.0/100 000 to 45.2/100 000) from 2002 to 2013, leveling at 46.4/100 000 (P<0.0001). PCI/CABG ratio increased from 3.6 in 2002 to 8.5 in 2013, slightly decreasing to 8.2 by 2014 (P<0.0001). In-hospital procedural mortality remained stable (PCI: 1.2-1.6%, P=0.34, CABG: 3.7-4.4%, P=0.29) despite a significant change in patient clinical profile. During the course of the study, ischemic heart disease-related mortality decreased by 46% (84.6-46/100 000, P<0.001).

CONCLUSIONS

We observed a dramatic change in coronary revascularization procedures type and volume, and a marked decrease in ischemic heart disease-related mortality in Israel. The reasons for the observed changes remain unclear and need to be further investigated.