1
|
Möllenkamp M, Pongiglione B, Rabbe S, Torbica A, Schreyögg J. Spillover effects and other determinants of medical device uptake in the presence of a medical guideline: An analysis of drug-eluting stents in Germany and Italy. HEALTH ECONOMICS 2022; 31 Suppl 1:157-178. [PMID: 36030527 DOI: 10.1002/hec.4587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 06/28/2022] [Accepted: 07/26/2022] [Indexed: 06/15/2023]
Abstract
We investigated the role of spillover effects among hospitals in the diffusion of drug-eluting stents (DES) in Germany and Italy during a period in which the relevant medical guideline clearly recommended their use over bare-metal stents. We used administrative data of hospitalized patients treated with ST-elevation myocardial infarction from 2012 to 2016 to estimate spatial panel models allowing for global spillover effects. We used an inverse-distance weights matrix to capture the geographical proximity between neighboring hospitals and assigned a lower weight to more distant neighbors. For both countries, we found significant positive spatial autocorrelation in most years based on the global Moran's I test, and a significant, positive spatial lag parameter across model specifications, indicating positive spillover effects among neighboring hospitals. We found that private for-profit hospital ownership and hospital competition in Germany and the number of inpatient cases with circulatory system diseases in Italy were other significant determinants of DES adoption. Our results underline the importance of spillover effects among peers for the diffusion of medical devices even in the presence of a positive guideline recommendation. Policymakers might therefore consider promoting various forms of exchange and collaboration among medical staff and hospitals to ensure the appropriate use of medical technologies.
Collapse
Affiliation(s)
- Meilin Möllenkamp
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | | | - Stefan Rabbe
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Aleksandra Torbica
- Center for Research on Health and Social Care Management, SDA Bocconi, Milan, Italy
| | - Jonas Schreyögg
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| |
Collapse
|
2
|
Feldman DA, Shroff AR, Bao H, Curtis JP, Minges KE, Ardati AK. Stent selection among patients with chronic kidney disease: Results from the NCDR CathPCI Registry. Catheter Cardiovasc Interv 2020; 96:1213-1221. [PMID: 31909543 DOI: 10.1002/ccd.28698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/20/2019] [Indexed: 11/05/2022]
Abstract
OBJECTIVES This study sought to define contemporary rates of drug eluting stent (DES) usage in patients with chronic kidney disease (CKD). BACKGROUND Among patients with CKD undergoing percutaneous coronary interventions (PCIs), outcomes are superior for those who receive DES compared to those who receive bare metal stents (BMSs). However, perceived barriers may limit the use of DES in this population. METHODS All adult PCI cases from the NCDR CathPCI Registry involving coronary stent placement between July 1, 2009 and December 31, 2015 were analyzed. The rate of DES usage was then compared among four groups, stratified by CKD stage (I/II, III, IV, and V). Subgroup analysis was conducted based on PCI status and indication. Cases were linked to Medicare claims data to assess 1-year mortality. RESULTS A total of 3,650,333 PCI cases met criteria for analysis. DES usage significantly declined as renal function worsened (83.0%, 79.9%, 75.6%, and 75.6%, respectively, in the four CKD stages; p < .001). DES usage was universally lower across the four groups in the setting of ST-Elevation Myocardial Infarction (STEMI) (70.6%, 66.5%, 58.7%, 58.0%; p < .001) and higher in the setting of elective PCI (87.6%, 84.9%, 82.3%, 77.9%; p < .0001). DES was associated with improved 1-year survival, and usage increased over time across each group. CONCLUSIONS DESs are underutilized in patients with advanced renal dysfunction. Although DES usage has increased over time, variation still exists between patients with normal renal function and those with CKD.
Collapse
Affiliation(s)
- Daniel A Feldman
- Section of Cardiology, Adventist Health Portland, Portland, Oregon
| | - Adhir R Shroff
- Division of Cardiology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Haikun Bao
- Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Karl E Minges
- Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Amer K Ardati
- Division of Cardiology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| |
Collapse
|
3
|
DeVore AD, Yow E, Krucoff MW, Sherwood MW, Shaw LK, Chiswell K, O'Connor CM, Ohman EM, Velazquez EJ. Percutaneous coronary intervention outcomes in patients with stable coronary disease and left ventricular systolic dysfunction. ESC Heart Fail 2019; 6:1233-1242. [PMID: 31560171 PMCID: PMC6989282 DOI: 10.1002/ehf2.12510] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/27/2019] [Accepted: 07/30/2019] [Indexed: 01/06/2023] Open
Abstract
AIMS We sought to better understand the role of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) and moderate or severe left ventricular systolic dysfunction. METHODS AND RESULTS Using data from the Duke Databank for Cardiovascular Disease, we analysed patients who underwent coronary angiography at Duke University Medical Center (1995-2012) that had stable CAD amenable to PCI and left ventricular ejection fraction ≤35%. Patients with acute coronary syndrome or Canadian Cardiovascular Society class III or IV angina were excluded. We used propensity-matched Cox proportional hazards to evaluate the association of PCI with mortality and hospitalizations. Of 901 patients, 259 were treated with PCI and 642 with medical therapy. PCI propensity scores created from 24 variables were used to assemble a matched cohort of 444 patients (222 pairs) receiving PCI or medical therapy alone. Over a median follow-up of 7 years, 128 (58%) PCI and 125 (56%) medical therapy alone patients died [hazard ratio 0.87 (95% confidence interval 0.68, 1.10)]; there was also no difference in the rate of a composite endpoint of all-cause mortality or cardiovascular hospitalization [hazard ratio 1.18 (95% confidence interval 0.96, 1.44)] between the two groups. CONCLUSIONS In this well-profiled, propensity-matched cohort of patients with stable CAD amenable to PCI and moderate or severe left ventricular systolic dysfunction, the addition of PCI to medical therapy did not improve long-term mortality, or the composite of mortality or cardiovascular hospitalization. The impact of PCI on other outcomes in these high-risk patients requires further study.
Collapse
Affiliation(s)
- Adam D DeVore
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, 200 Morris Street, 6318, Durham, NC, 27701, USA
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Morris Street, 6318, Durham, NC, 27701, USA
| | - Mitchell W Krucoff
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, 200 Morris Street, 6318, Durham, NC, 27701, USA
| | | | - Linda K Shaw
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Morris Street, 6318, Durham, NC, 27701, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Morris Street, 6318, Durham, NC, 27701, USA
| | | | - Erik Magnus Ohman
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, 200 Morris Street, 6318, Durham, NC, 27701, USA
| | | |
Collapse
|
4
|
Rymer JA, Harrison RW, Dai D, Roe MT, Messenger JC, Anderson HV, Peterson ED, Wang TY. Trends in Bare-Metal Stent Use in the United States in Patients Aged ≥65 Years (from the CathPCI Registry). Am J Cardiol 2016; 118:959-66. [PMID: 27614853 DOI: 10.1016/j.amjcard.2016.06.061] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 12/19/2022]
Abstract
In 2006, the United States (US) Food and Drug Administration published advisory highlighting concerns for late drug-eluting stent thrombosis; its impact on US bare-metal stent (BMS) utilization is unknown. We examined rates of BMS use among Medicare patients at 946 US hospitals in the CathPCI Registry who underwent percutaneous coronary intervention (PCI) during 3 periods: (1) 2004 to 2006 preadvisory (n = 166,458); (2) 2007 to 2008 postadvisory (n = 216,318); and (3) 2012 to 2014 contemporary (n = 827,948). We examined predicted risks of target vessel revascularization and bleeding among BMS recipients by period. We compared 1-year repeat revascularization and death/myocardial infarction risks among BMS recipients immediately preadvisory and postadvisory. BMS were used in 15.8% of preadvisory, 40.9% of postadvisory, and 20.0% of contemporary PCI procedures. Although 19.5% of preadvisory BMS patients had a predicted target vessel revascularization risk ≥15%/year, this decreased to 16.7% postadvisory (p <0.001), and increased back to 18.7% among contemporary BMS recipients (p <0.001). In contrast, 12.3% of preadvisory BMS recipients had a predicted bleeding risk ≥5%/year, compared with 14.6% postadvisory (p <0.001), and 18.2% in contemporary BMS recipients (p <0.001). Postadvisory BMS recipients had a lower risk of repeat revascularization (12.8% vs 14.6%, adjusted hazard ratio 0.87, 95% CI 0.84 to 0.90) but no difference in the composite risk of death/myocardial infarction (15.9% vs 15.9%, adjusted hazard ratio 0.97, 95% CI 0.93 to 1.00). In conclusion, a surge in BMS use after the advisory was not associated with an increased risk of repeat revascularization or adverse outcomes in BMS-treated patients. One in 5 contemporary PCI procedures still involve BMS implantation.
Collapse
|
5
|
Chang TI, Montez-Rath ME, Tsai TT, Hlatky MA, Winkelmayer WC. Drug-Eluting Versus Bare-Metal Stents During PCI in Patients With End-Stage Renal Disease on Dialysis. J Am Coll Cardiol 2016; 67:1459-1469. [PMID: 27012407 DOI: 10.1016/j.jacc.2015.10.104] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/11/2015] [Accepted: 10/20/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND In patients undergoing percutaneous coronary intervention (PCI), drug-eluting stents (DES) reduce repeat revascularizations compared with bare-metal stents (BMS), but their effects on death and myocardial infarction (MI) are mixed. Few studies have focused on patients with end-stage renal disease. OBJECTIVES This study compared mortality and cardiovascular morbidity during percutaneous coronary intervention with DES and with BMS in dialysis patients. METHODS We identified 36,117 dialysis patients from the USRDS (United States Renal Data System) who had coronary stenting in the United States between April 23, 2003, and December 31, 2010, and examined the association of DES versus BMS with 1-year outcomes: death; death or MI; and death, MI, or repeat revascularization. We also conducted a temporal analysis by dividing the study period into 3 DES eras: Transitional (April 23, 2003, to June 30, 2004); Liberal (July 1, 2004, to December 31, 2006); and Selective (January 1, 2007, to December 31, 2010). RESULTS One-year event rates were high, with 38 deaths; 55 death or MI events; and 71 death, MI, or repeat revascularization events per 100 person-years. DES, compared with BMS, were associated with a significant 18% lower risk of death; 16% lower risk of death or MI; and 13% lower risk of death, MI, or repeat revascularization. DES use varied, from 56% in the Transitional era to 85% in the Liberal era and 62% in the Selective era. DES outcomes in the Liberal era were significantly better than in the Transitional Era, but not significantly better than in the Selective Era. CONCLUSIONS DES for percutaneous coronary intervention appears to be safe for use in U.S. dialysis patients and is associated with lower rates of death, MI, and repeat revascularization.
Collapse
Affiliation(s)
- Tara I Chang
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California.
| | - Maria E Montez-Rath
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Thomas T Tsai
- Interventional Cardiology & Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Consortium, University of Colorado, Denver, Colorado
| | - Mark A Hlatky
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Wolfgang C Winkelmayer
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
6
|
Kang HJ, Simon D, Wang TY, Alexander KP, Jeong MH, Kim HS, Bates ER, Henry TD, Peterson ED, Roe MT. The Contemporary Use of Angiography and Revascularization Among Patients With Non-ST-Segment Elevation Myocardial Infarction in the United States Compared With South Korea. Clin Cardiol 2015; 38:708-14. [PMID: 26782938 DOI: 10.1002/clc.22475] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Practice guidelines recommend an early invasive strategy for high-risk non-ST-segment elevation myocardial infarction (NSTEMI) patients, but international differences in the use of invasive strategies are unknown. HYPOTHESIS Profiling NSTEMI patient management in the United States (U.S.) and South Korea could provide insight into how patients are triaged for an early invasive strategy in different health care environments and geographical regions. METHODS We evaluated the use of angiography and revascularization for NSTEMI patients treated at revascularization-capable hospitals (2007-2010) in both the ACTION Registry-GWTG (U.S.: n = 133,835; 433 hospitals) and KAMIR/KorMI Registry (South Korea: n = 7,901; 72 hospitals). RESULTS Compared with South Korean patients, U.S. NSTEMI patients more commonly had established cardiovascular risk factors, disease, and prior cardiovascular events and procedures. From 2007-2010, the use of angiography for NSTEMI patients rose steadily in both countries, but the use of revascularization only rose in South Korea. Patients from South Korea more commonly underwent angiography and revascularization. Percutaneous coronary intervention was the most common type of revascularization in both countries, but coronary artery bypass grafting was less common in South Korea. The use of both angiography and revascularization was incrementally lower with a higher predicted mortality risk for patients from both countries, but greater differences between low- and high-risk patients occurred in the U.S. CONCLUSIONS The profile, characteristics, and use of angiography and revascularization for NSTEMI patients in the U.S. vs South Korea differed substantially from 2007-2010, underscoring the heterogeneity of NSTEMI patients and treatment selection among different countries.
Collapse
Affiliation(s)
- Hyun-Jae Kang
- Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina.,Department of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Dajuanicia Simon
- Department of Biostatistics, Duke Clinical Research Institute, Durham, North Carolina
| | - Tracy Y Wang
- Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Karen P Alexander
- Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Myung Ho Jeong
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Eric R Bates
- Department of Internal Medicine, University of Michigan Hospitals, Ann Arbor, Michigan
| | - Timothy D Henry
- Department of Medicine, Cedars Sinai Heart Institute, Advanced Health Sciences Pavilion, Los Angeles, California
| | - Eric D Peterson
- Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Matthew T Roe
- Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | | |
Collapse
|
7
|
Panaich SS, Badheka AO, Arora S, Patel NJ, Thakkar B, Patel N, Singh V, Chothani A, Deshmukh A, Agnihotri K, Jhamnani S, Lahewala S, Manvar S, Panchal V, Patel A, Patel N, Bhatt P, Savani C, Patel J, Savani GT, Solanki S, Patel S, Kaki A, Mohamad T, Elder M, Kondur A, Cleman M, Forrest JK, Schreiber T, Grines C. Variability in utilization of drug eluting stents in United States: Insights from nationwide inpatient sample. Catheter Cardiovasc Interv 2015; 87:23-33. [DOI: 10.1002/ccd.25977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 03/25/2015] [Accepted: 04/04/2015] [Indexed: 11/10/2022]
Affiliation(s)
| | - Apurva O. Badheka
- Department of Cardiology, Yale School of Medicine; New Haven Connecticut
| | - Shilpkumar Arora
- Department of Internal Medicine, Mount Sinai St. Luke's Roosevelt Hospital; New York New York
| | - Nileshkumar J. Patel
- Department of Internal Medicine; Staten Island University Hospital; Staten Island New York
| | - Badal Thakkar
- Department of Internal Medicine; Tulane School of Public Health & Tropical Medicine; New Orleans Louisiana
| | - Nilay Patel
- Department of Internal Medicine; Saint Peter's University Hospital; New Brunswick New Jersey
| | - Vikas Singh
- Department of Cardiology; University of Miami Miller School of Medicine; Miami Florida
| | - Ankit Chothani
- Department of Internal Medicine; MedStar Washington Hospital Center; Washington District of Columbia
| | | | - Kanishk Agnihotri
- Department of Internal Medicine; Saint Peter's University Hospital; New Brunswick New Jersey
| | - Sunny Jhamnani
- Department of Cardiology, Yale School of Medicine; New Haven Connecticut
| | - Sopan Lahewala
- Department of Internal Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | | | - Vinaykumar Panchal
- Department of Internal Medicine; Tulane School of Public Health & Tropical Medicine; New Orleans Louisiana
| | - Achint Patel
- Department of Internal Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - Neil Patel
- Department of Internal Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - Parth Bhatt
- Department of Internal Medicine; Tulane School of Public Health & Tropical Medicine; New Orleans Louisiana
| | - Chirag Savani
- Department of Internal Medicine; New York Medical College; Valhalla New York
| | - Jay Patel
- Detroit Medical Center; Detroit Michigan
| | | | - Shantanu Solanki
- Department of Internal Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - Samir Patel
- Department of Internal Medicine, Western Reserve Health System; Youngstown Ohio
| | - Amir Kaki
- Detroit Medical Center; Detroit Michigan
| | | | | | | | - Michael Cleman
- Department of Cardiology, Yale School of Medicine; New Haven Connecticut
| | - John K. Forrest
- Department of Cardiology, Yale School of Medicine; New Haven Connecticut
| | | | | |
Collapse
|
8
|
Hlatky MA, Boothroyd DB, Baker LC, Go AS. Impact of drug-eluting stents on the comparative effectiveness of coronary artery bypass surgery and percutaneous coronary intervention. Am Heart J 2015; 169:149-54. [PMID: 25497260 DOI: 10.1016/j.ahj.2014.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Drug-eluting stents (DES) have largely replaced bare-metal stents (BMS) for percutaneous coronary intervention (PCI). It is uncertain, however, whether introduction of DES had a significant impact on the comparative effectiveness of PCI versus coronary artery bypass graft surgery (CABG) for death and myocardial infarction (MI). METHODS We identified Medicare beneficiaries aged ≥66 years who underwent multivessel CABG or multivessel PCI and matched PCI and CABG patients on propensity score. We defined the BMS era as January 1999 to April 2003 and the DES era as May 2003 to December 2006. We compared 5-year outcomes of CABG and PCI using Cox proportional hazards models, adjusting for baseline characteristics and year of procedure and tested for a statistically significant interaction (P(int)) of DES era with treatment (CABG or PCI). RESULTS Five-year survival improved from the BMS era to the DES era by 1.2% for PCI and by 1.1% for CABG, and the CABG:PCI hazard ratio was unchanged (0.90 vs 0.90; P(int) = .96). Five-year MI-free survival improved by 1.4% for PCI and 1.1% for CABG, with no change in the CABG:PCI hazard ratio (0.81 vs 0.82; P(int) = .63). By contrast, survival-free of MI or repeat coronary revascularization improved from the BMS era to the DES era by 5.7% for PCI and 0.9% for CABG, and the CABG:PCI hazard ratio changed significantly (0.50 vs 0.57, P(int) ≤ .0001). CONCLUSIONS The introduction of DES did not alter the comparative effectiveness of CABG and PCI with respect to hard cardiac outcomes.
Collapse
Affiliation(s)
- Mark A Hlatky
- Stanford University School of Medicine, Stanford, CA.
| | | | | | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; University of California San Francisco School of Medicine, San Francisco, CA
| |
Collapse
|
9
|
Gatto P, Carrié D. Coronary artery disease evolution in bare-metal stent implantation: safety and efficacy of REBEL™ platinum–chromium coronary stent system. Interv Cardiol 2014. [DOI: 10.2217/ica.14.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
10
|
Carrie D, Schächinger V, Danzi GB, Macaya C, Zeymer U, Putnikovic B, Iniguez A, Moreno R, Mehmedbegovic Z, Beleslin B. Cobalt-chromium KAname™ coRonary stEnt system in the treatment of patients with coronary artery disease (KARE study). J Interv Cardiol 2014; 27:491-9. [PMID: 25175153 DOI: 10.1111/joic.12144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To evaluate the safety and effectiveness of the Kaname™ cobalt-chromium (Co-Cr), thin strut, bare metal stent (BMS) system for the treatment of coronary artery lesions. BACKGROUND Despite widespread use of drug-eluting stents, a certain percentage of patients with coronary artery disease are still treated with BMS. Therefore, it is essential to evaluate their clinical performance. METHODS Two hundred eighty-two patients were enrolled in this prospective, single-arm study including a predefined subset of 79 patients with small vessels. The primary end-point was freedom from target vessel failure (TVF) at 6 months. Key angiographic and intravascular ultrasound (IVUS) end-points were late loss, diameter stenosis, binary restenosis, and neointimal hyperplasia volume. RESULTS Freedom from TVF at 6 months was 93.3% and at 1 year 90.8% in total population, and 92.4% and 87.3% in small vessels, respectively. Clinically driven target lesion revascularization (TLR) rates at 6 and 12 months were 4.3% and 6.4% in total population, and 3.8% and 7.6% in small vessels, respectively. At 6 months in-stent late loss was 0.75 ± 0.43 mm and binary restenosis rate was 16.9% in total population, and 0.64 ± 0.40 mm and 26.1% in small vessels, while IVUS assessed neointimal hyperplasia volume at 6 months was 128.9 ± 42.6 mm(3) for total population. There were no definite and probable stent thromboses up to 12 months. CONCLUSIONS Results indicate good safety and effectiveness of the Kaname™ stent with clinically equivalent results in small and larger vessels, as such providing useful treatment option for patients with ischemic heart disease considered for BMS implantation.
Collapse
|
11
|
Dubois RW, Lauer M, Perfetto E. When is evidence sufficient for decision-making? A framework for understanding the pace of evidence adoption. J Comp Eff Res 2014; 2:383-91. [PMID: 24236680 DOI: 10.2217/cer.13.39] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Translation of medical evidence into practice has not kept pace with the growth of medical technology and knowledge. We present three case studies--statins, drug eluting stents and bone marrow transplantation for breast cancer--to propose a framework for describing five factors that may influence the rate of adoption. The factors are: validity, reliability and maturity of the science available before widespread adoption; communication of the science; economic drivers; patients' and physicians' ability to apply published scientific findings to their specific clinical needs; and incorporation into practice guidelines.
Collapse
Affiliation(s)
- Robert W Dubois
- National Pharmaceutical Council, 1717 Pennsylvania Avenue, NW, Suite 800, Washington, DC 20006, USA.
| | | | | |
Collapse
|
12
|
Loh JP, Torguson R, Pendyala LK, Omar A, Chen F, Satler LF, Pichard AD, Waksman R. Impact of early versus late clopidogrel discontinuation on stent thrombosis following percutaneous coronary intervention with first- and second-generation drug-eluting stents. Am J Cardiol 2014; 113:1968-76. [PMID: 24767975 DOI: 10.1016/j.amjcard.2014.03.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/17/2014] [Accepted: 03/17/2014] [Indexed: 10/25/2022]
Abstract
Premature antiplatelet therapy discontinuation (ATD) after drug-eluting stent (DES) implantation is known to predict stent thrombosis (ST). However, recent data suggest that a shorter antiplatelet therapy duration is safe with newer generation DESs. The study aimed to compare the impact of early and late clopidogrel ATDs on ST in a real-world registry of first- and second-generation DES use. A total of 6,236 patients who underwent DES implantation were analyzed retrospectively: 4,217 received first-generation DESs (sirolimus- and paclitaxel-eluting stents) and 2,019 received second-generation DESs (everolimus-eluting stents). Within each DES cohort, patients were categorized into timing of clopidogrel discontinuation within 1 year: early (<3 months), late (3 to 12 months), and continued. ST rates and clinical outcomes at 1 year were analyzed. There were 341 patients (8.1%) in the first-generation DES group and 126 patients (6.2%) in the second-generation DES group who discontinued clopidogrel within the first year. Definite and probable ST rates were 3.8% for early ATD, 2.5% for late ATD, and 0.5% for continued (p = 0.001) in the first-generation DES cohort, whereas there were no definite or probable ST events in early and late ATDs and 0.5% for continued in the second-generation DES cohort. Major adverse cardiac event rates were 9.9% for early ATD, 5.6% for late ATD, and 0.9% for continued (p <0.001) in the first-generation DES cohort and 5.5% for early ATD, 7.4% for late ATD, and 1.5% for continued (p <0.001) in the second-generation DES cohort. In conclusion, ATD within the first year is associated with increased ST events with first-generation DESs, whereas ATD appears safe with second-generation DESs with regard to ST. However, ATD is associated with greater mortality and major adverse cardiac events in both first- and second-generation DESs. Thus, this study supports ATD if required based on physician discretion with the use of second-generation DESs but cannot rule out potential benefit for longer duration of dual antiplatelet therapy even when second-generation DESs are used.
Collapse
|
13
|
Tomey MI, Kini AS, Sharma SK. Current Status of Rotational Atherectomy. JACC Cardiovasc Interv 2014; 7:345-53. [DOI: 10.1016/j.jcin.2013.12.196] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 12/05/2013] [Accepted: 12/19/2013] [Indexed: 01/06/2023]
|
14
|
Tada T, Byrne RA, Simunovic I, King LA, Cassese S, Joner M, Fusaro M, Schneider S, Schulz S, Ibrahim T, Ott I, Massberg S, Laugwitz KL, Kastrati A. Risk of Stent Thrombosis Among Bare-Metal Stents, First-Generation Drug-Eluting Stents, and Second-Generation Drug-Eluting Stents. JACC Cardiovasc Interv 2013; 6:1267-74. [DOI: 10.1016/j.jcin.2013.06.015] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 06/07/2013] [Accepted: 06/20/2013] [Indexed: 10/25/2022]
|
15
|
Yeh RW, Vasaiwala S, Forman DE, Silbaugh TS, Zelevinski K, Lovett A, Normand SLT, Mauri L. Instrumental Variable Analysis to Compare Effectiveness of Stents in the Extremely Elderly. Circ Cardiovasc Qual Outcomes 2013; 7:118-24. [DOI: 10.1161/circoutcomes.113.000476] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
16
|
Hlatky MA, Boothroyd DB, Reitz BA, Shilane DA, Baker LC, Go AS. Adoption and effectiveness of internal mammary artery grafting in coronary artery bypass surgery among Medicare beneficiaries. J Am Coll Cardiol 2013; 63:33-9. [PMID: 24080110 DOI: 10.1016/j.jacc.2013.08.1632] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 08/27/2013] [Accepted: 08/28/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The aim of this study was to assess the pattern of the adoption of internal mammary artery (IMA) grafting in the United States, test its association with clinical outcomes, and assess whether its effectiveness differs in key clinical subgroups. BACKGROUND The effect of IMA grafting on major clinical outcomes has never been tested in a large randomized trial, yet it is now a quality standard for coronary artery bypass graft (CABG) surgery. METHODS We identified Medicare beneficiaries ≥66 years of age who underwent isolated multivessel CABG between 1988 and 2008, and we documented patterns of IMA use over time. We used a multivariable propensity score to match patients with and without an IMA and compared rates of death, myocardial infarction (MI), and repeat revascularization. We tested for variations in IMA effectiveness with treatment × covariate interaction tests. RESULTS The IMA use in CABG rose slowly from 31% in 1988 to 91% in 2008, with persistent wide geographic variations. Among 60,896 propensity score-matched patients over a median 6.8-year follow-up, IMA use was associated with lower all-cause mortality (adjusted hazard ratio: 0.77, p < 0.001), lower death or MI (adjusted hazard ratio: 0.77, p < 0.001), and fewer repeat revascularizations over 5 years (8% vs. 9%, p < 0.001). The association between IMA use and lower mortality was significantly weaker (p ≤ 0.008) for older patients, women, and patients with diabetes or peripheral arterial disease. CONCLUSIONS Internal mammary artery grafting was adopted slowly and still shows substantial geographic variation. IMA use is associated with lower rates of death, MI, and repeat coronary revascularization.
Collapse
Affiliation(s)
- Mark A Hlatky
- Stanford University School of Medicine, Stanford, California.
| | | | - Bruce A Reitz
- Stanford University School of Medicine, Stanford, California
| | - David A Shilane
- Stanford University School of Medicine, Stanford, California
| | - Laurence C Baker
- Stanford University School of Medicine, Stanford, California; National Bureau of Economic Research, Cambridge, Massachusetts
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| |
Collapse
|
17
|
Yong AS, Tremmel JA. Can we bear another bare-metal stent study? Catheter Cardiovasc Interv 2013; 81:1095-6. [PMID: 23704063 DOI: 10.1002/ccd.24964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 04/13/2013] [Indexed: 11/06/2022]
|
18
|
Gordon PC, Cohen DJ, Kleiman NS, Montgomery JA, Semder CA, Kennedy KF, Keyes MJ, Piana RN. In-hospital and one year outcomes with drug-eluting versus bare metal stents in large native coronary arteries: A report from the evaluation of drug-eluting stents and ischemic events registry. Catheter Cardiovasc Interv 2013; 82:E356-64. [DOI: 10.1002/ccd.24451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 04/12/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Paul C. Gordon
- Division of Cardiology; The Miriam Hospital; Providence; Rhode Island
| | - David J. Cohen
- Saint Luke's Mid America Heart Institute; Kansas City; Missouri
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Federspiel JJ, Stearns SC, Reiter KL, Geissler KH, Triplette MA, D'Arcy LP, Sheridan BC, Rossi JS. Disappearing and reappearing differences in drug-eluting stent use by race. J Eval Clin Pract 2013; 19:256-62. [PMID: 22132712 PMCID: PMC3297699 DOI: 10.1111/j.1365-2753.2011.01809.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Drug-eluting coronary stents (DES) rapidly dominated the marketplace in the United States after approval in 2003, but utilization rates were initially lower among African American patients. We assess whether racial differences persisted as DES diffused into practice. METHODS Medicare claims data were used to identify coronary stenting procedures among elderly patients with acute coronary syndromes (ACS). Regression models of the choice of DES versus bare mental stent controlled for demographics, ACS type, co-morbidities and hospital characteristics. Diffusion was assessed in the short run (2003-2004) and long run (2007), with the effect of race calculated to allow for time-varying effects. RESULTS The sample included 381,887 Medicare beneficiaries treated with stent insertion; approximately 5% were African American. Initially (May 2003-February 2004), African American race was associated with lower DES use compared to other races (44.3% versus 46.5%, P < 0.01). Once DES usage was high in all patients (March-December 2004), differences were not significant (79.8% versus 80.3%, P = 0.45). Subsequent concerns regarding DES safety caused reductions in DES use, with African Americans having lower use than other racial groups in 2007 (63.1% versus 65.2%, P < 0.01). CONCLUSIONS Racial disparities in DES use initially disappeared during a period of rapid diffusion and high usage rates; the reappearance of disparities in use by 2007 may reflect DES use tailored to unmeasured aspects of case mix and socio-economic status. Further work is needed to understand whether underlying differences in race reflect decisions regarding treatment appropriateness.
Collapse
Affiliation(s)
- Jerome J Federspiel
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7411, USA
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Byrne RA, Kastrati A, Hausleiter J. The battle against stent thrombosis--to protect and to serve. Lancet 2012; 380:1365-7. [PMID: 22951083 DOI: 10.1016/s0140-6736(12)61385-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Robert A Byrne
- Deutsches Herzzentrum and Klinikum rechts der Isar, Technische Universität, 80636 Munich, Germany
| | | | | |
Collapse
|
21
|
|
22
|
Palmerini T, Biondi-Zoccai G, Della Riva D, Stettler C, Sangiorgi D, D'Ascenzo F, Kimura T, Briguori C, Sabatè M, Kim HS, De Waha A, Kedhi E, Smits PC, Kaiser C, Sardella G, Marullo A, Kirtane AJ, Leon MB, Stone GW. Stent thrombosis with drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. Lancet 2012; 379:1393-402. [PMID: 22445239 DOI: 10.1016/s0140-6736(12)60324-9] [Citation(s) in RCA: 720] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The relative safety of drug-eluting stents and bare-metal stents, especially with respect to stent thrombosis, continues to be debated. In view of the overall low frequency of stent thrombosis, large sample sizes are needed to accurately estimate treatment differences between stents. We compared the risk of thrombosis between bare-metal and drug-eluting stents. METHODS For this network meta-analysis, randomised controlled trials comparing different drug-eluting stents or drug-eluting with bare-metal stents currently approved in the USA were identified through Medline, Embase, Cochrane databases, and proceedings of international meetings. Information about study design, inclusion and exclusion criteria, sample characteristics, and clinical outcomes was extracted. FINDINGS 49 trials including 50,844 patients randomly assigned to treatment groups were analysed. 1-year definite stent thrombosis was significantly lower with cobalt-chromium everolimus eluting stents (CoCr-EES) than with bare-metal stents (odds ratio [OR] 0·23, 95% CI 0·13-0·41). The significant difference in stent thrombosis between CoCr-EES and bare-metal stents was evident as early as 30 days (OR 0·21, 95% CI 0·11-0·42) and was also significant between 31 days and 1 year (OR 0·27, 95% CI 0·08-0·74). CoCr-EES were also associated with significantly lower rates of 1-year definite stent thrombosis compared with paclitaxel-eluting stents (OR 0·28, 95% CI 0·16-0·48), permanent polymer-based sirolimus-eluting stents (OR 0·41, 95% CI 0·24-0·70), phosphorylcholine-based zotarolimus-eluting stents (OR 0·21, 95% CI 0·10-0·44), and Resolute zotarolimus-eluting stents (OR 0·14, 95% CI 0·03-0·47). At 2-year follow-up, CoCr-EES were still associated with significantly lower rates of definite stent thrombosis than were bare-metal (OR 0·35, 95% CI 0·17-0·69) and paclitaxel-eluting stents (OR 0·34, 95% CI 0·19-0·62). No other drug-eluting stent had lower definite thrombosis rates compared with bare-metal stents at 2-year follow-up. INTERPRETATION In randomised studies completed to date, CoCr-EES has the lowest rate of stent thrombosis within 2 years of implantation. The finding that CoCr-EES also reduced stent thrombosis compared with bare-metal stents, if confirmed in future randomised trials, represents a paradigm shift. FUNDING The Cardiovascular Research Foundation.
Collapse
|
23
|
Abstract
BACKGROUND Despite receiving identical reimbursement for treating heart disease patients with bare metal stents (BMS) or drug-eluting coronary stents (DES), cardiologists' use of the new technology (DES) may have varied by patient payer type as DES diffused. Payer-related factors that differ between hospitals and/or differential treatment inside hospitals might explain any overall differences by payer type. OBJECTIVES To assess the association between payer and DES use and to examine between-hospital and within-hospital variation in DES use over time. METHODS We conducted a retrospective analysis of 4.1 million hospitalizations involving DES or BMS from 2003 to 2008 Nationwide Inpatient Sample. We estimated hybrid-fixed effects logit models and calculated the adjusted within-quarter, cross-payer differences in DES use. RESULTS Coronary stent patients with Medicaid or without insurance were significantly less likely to receive DES than were patients with private insurance throughout the study period. The differences fluctuated over time as the popularity of DES relative to BMS increased and decreased. The within-hospital gaps paralleled the overall differences, and were largest in Q3 2003 (Medicaid: 11.9, uninsured: 10.9% points) and Q4 2008 (Medicaid: 12.8, uninsured: 20.7% points), and smallest in Q4 2004 (Medicaid: 1.4, uninsured: 1.1% points). The between-hospital adjusted differences in DES use by payer were small and rarely significant. CONCLUSIONS We found substantial differences in DES use by payer within hospitals, suggesting physicians selected the new technology for patients in a manner associated with patients' payer type.
Collapse
|
24
|
Novel nanocomposite stent coating releasing resveratrol and quercetin reduces neointimal hyperplasia and promotes re-endothelialization. J Control Release 2012; 159:27-33. [PMID: 22269665 DOI: 10.1016/j.jconrel.2012.01.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 01/04/2012] [Accepted: 01/10/2012] [Indexed: 11/21/2022]
Abstract
Late-term thrombosis associated with drug-eluting stents may be due to the non-selective actions of antimitogenic drugs on endothelial cells, leading to delayed vascular healing after stenting angioplasty. Currently, there is a need for stent-based therapies that can both attenuate neointimal hyperplasia and promote re-endothelialization. The aim of this study was to compare the effects of a resveratrol (R)- and quercetin (Q)-eluting stent with that of a bare metal stent (BMS) on neointimal hyperplasia and re-endothelialization in a rat model of arterial angioplasty and stenting. Miniature stents (2.5×1.25mm) were sprayed with nanocomposite coatings containing two concentrations of R:Q (50:25μg/cm(2) (RQ1) or 150:75μg/cm(2) (RQ2)). The stents were deployed into the common carotid artery of rats and their impact on vascular remodeling was compared to that of BMS. Luminal stenosis in arteries stented with RQ2-eluting stents was reduced by 64.6% (p<0.05) compared to arteries stented with BMS. Accompanying this effect was a 59.8% reduction in macrophage infiltration (p<0.05). There were no differences found between RQ1 and BMS. Finally, the RQ2-coated stent accelerated re-endothelialization by 50% compared with BMS (p<0.05). Thus, compared with BMS, local delivery of R and Q from a stent platform significantly reduced in-stent stenosis, while promoting re-endothelialization. These data suggest that R and Q may be favorable candidates for novel stent coatings, potentially reducing the risk of late thrombosis associated with drug-eluting stents.
Collapse
|
25
|
Rosenfeldt FL, Wilson MD, Buxton BF, Marasco SF. Coronary Artery Bypass Surgery Provides Long-Term Results Superior to Percutaneous Coronary Intervention. Heart Lung Circ 2012; 21:1-11. [DOI: 10.1016/j.hlc.2011.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Revised: 08/05/2011] [Accepted: 08/15/2011] [Indexed: 01/01/2023]
|
26
|
Stolker JM, Cohen DJ, Lindsey JB, Kennedy KF, Kleiman NS, Marso SP. Mode of death after contemporary percutaneous coronary intervention: a report from the Evaluation of Drug Eluting Stents and Ischemic Events registry. Am Heart J 2011; 162:914-21. [PMID: 22093209 DOI: 10.1016/j.ahj.2011.08.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 08/19/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND When selecting clinical trial end points, some investigators prefer cardiovascular death (CVD) while others believe that all-cause mortality is more relevant. However, the relative contribution of CVD to 1-year mortality after contemporary percutaneous coronary intervention (PCI) is not known. METHODS We evaluated the mode of death (MOD) in EVENT, a prospective PCI registry at 55 US hospitals. Vital status was assessed at 6 and 12 months as part of the study protocol, and MOD was independently reviewed in blinded fashion. RESULTS Between 2004 and 2007, EVENT enrolled 10,144 patients of whom 295 (2.9%) died within the first year: 51 (17%) ≤30 days; and 244 (83%) between 31 and 365 days after index PCI. Overall, CVD accounted for 42% of deaths, and no clear cause could be identified in a substantial subgroup (25% of deaths). Among patients who died ≤30 days, the MOD was more likely to be CVD (odds ratio 3.96, 95% CI 2.08-7.55), whereas the incidence of CVD and non-CVD was similar after 30 days. Findings were similar after a series of sensitivity analyses including reassignment of unknown MOD to the CVD category, using multiple imputation modeling, or when evaluating MOD in prespecified subgroups of patients with diabetes, acute coronary syndromes, or left ventricular dysfunction. CONCLUSIONS Among unselected PCI patients, 1-year mortality is approximately 3%, and CVD is confirmed in <50% of all deaths. Regardless of analytic approach, CVD is the primary contributor to overall mortality during the first 30 days after PCI, whereas rates of CVD and non-CVD are remarkably similar after the first month after PCI.
Collapse
|
27
|
Wu C, Zhao S, Wechsler AS, Lahey S, Walford G, Culliford AT, Gold JP, Smith CR, Holmes DR, King SB, Higgins RSD, Jordan D, Hannan EL. Long-term mortality of coronary artery bypass grafting and bare-metal stenting. Ann Thorac Surg 2011; 92:2132-8. [PMID: 22014747 DOI: 10.1016/j.athoracsur.2011.06.061] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 06/14/2011] [Accepted: 06/16/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND There is little information on relative survival with follow-up longer than 5 years in patients undergoing coronary artery bypass grafting (CABG) and patients undergoing percutaneous coronary intervention (PCI) with stenting. This study tested the hypothesis that CABG is associated with a lower risk of long-term (8-year) mortality than is stenting with bare-metal stents for multivessel coronary disease. METHODS We identified 18,359 patients with multivessel disease who underwent isolated CABG and 13,377 patients who received bare-metal stenting in 1999 to 2000 in New York and followed their vital status through 2007 using the National Death Index (NDI). We matched CABG and stent patients on the number of diseased coronary vessels, proximal left anterior descending (LAD) artery disease, and propensity of undergoing CABG based on numerous patient characteristics and compared survival after the 2 procedures. RESULTS In the 7,235 pairs of matched patients, the overall 8-year survival rates were 78.0% for CABG and 71.2% for stenting (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.64 to 0.74; p < 0.001). For anatomic groups classified by the number of diseased vessels and proximal LAD involvement, the HRs ranged from 0.53 (p < 0.001) for patients with 3-vessel disease involving proximal LAD artery disease to 0.78 (p = 0.05) for patients with 2-vessel disease but no disease in the LAD artery. A lower risk of death after CABG was observed in all subgroups stratified by a number of baseline risk factors. CONCLUSIONS Coronary artery bypass grafting is associated with a lower risk of death than is stenting with bare metal stents for multivessel coronary disease.
Collapse
Affiliation(s)
- Chuntao Wu
- Department of Public Health Sciences, Penn State Hershey College of Medicine, Hershey, Pennsylvania 17033, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Abstract
CONTEXT Coronary revascularization is among the most common hospital-based major interventional procedures performed in the United States. It is uncertain how new revascularization technologies, new clinical evidence from trials, and updated clinical guidelines have influenced the volume and distribution of coronary revascularizations over the past decade. OBJECTIVE To examine national time trends in the rates and types of coronary revascularizations. DESIGN, SETTING, AND PATIENTS A serial cross-sectional study with time trends of patients undergoing coronary artery bypass graft (CABG) surgery or percutaneous coronary interventions (PCIs) between 2001 and 2008 at US hospitals in the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, which reports inpatient coronary revascularizations. These data were supplemented by Medicare outpatient hospital claims. MAIN OUTCOME MEASURES Annual procedure rates of coronary revascularizations, CABG surgery, and PCI. RESULTS A 15% decrease (P < .001) in the annual rate of coronary revascularizations was observed from 2001-2002 to 2007-2008. The annual CABG surgery rate decreased steadily from 1742 (95% confidence interval [CI], 1663-1825) CABG surgeries per million adults per year in 2001-2002 to 1081 (95% CI, 1032-1133) CABG surgeries per million adults per year in 2007-2008 (P < .001), but PCI rates did not significantly change (3827 [95% CI, 3578-4092] PCI per million adults per year in 2001-2002 vs 3667 [95% CI, 3429-3922] PCI per million adults per year in 2007-2008, P = .74). Between 2001 and 2008, the number of hospitals in the Nationwide Inpatient Sample providing CABG surgery increased by 12% (212 in 2001 vs 241 in 2008, P = .03), and the number of PCI hospitals increased by 26% (246 in 2001 vs 331 in 2008, P < .001). The median CABG surgery caseload per hospital decreased by 28% (median [interquartile range], 253 [161-458] in 2001 vs 183 [98-292] in 2008; P < .001) and the number of CABG surgery hospitals providing fewer than 100 CABG surgeries per year increased from 23 (11%) in 2001 to 62 (26%) in 2008 (P < .001). CONCLUSIONS In US hospitals between 2001 and 2008, a substantial decrease in CABG surgery utilization rates was observed, but PCI utilization rates remained unchanged.
Collapse
Affiliation(s)
- Andrew J Epstein
- Department of Veterans Affairs' Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania, USA
| | | | | | | | | |
Collapse
|
29
|
Affiliation(s)
- Edward J. McNulty
- From the Kaiser Permanente San Francisco Medical Center and University of California San Francisco School of Medicine, San Francisco, CA
| |
Collapse
|
30
|
Abstract
The cancer patient with coronary disease presents particular challenges that directly impact on the management of coronary disease, both stable and acute. The frequent need for surgery in the cancer patient is an important consideration in avoiding a coronary artery stent or any percutaneous coronary intervention for management of chronic stable angina, which will delay surgery or pose of risk of stent thrombosis during surgery. Cancer surgery is considered low or intermediate cardiac risk so revascularization before surgery is needed only in exceptional circumstances. Medical treatment in most patients or coronary artery bypass graft in high risk situations may be preferable if the cancer is being actively treated. The likelihood of thrombocytopenia, either primary from bone marrow disease, or secondarily during chemotherapy causes concern about the need for continuous use of platelet suppressing agents, aspirin for all patients, or double antiplatelet therapy in all patients after receiving a coronary artery stent. Drug-eluting stents pose special problems and should be avoided. Even bare metal stents may have a higher long-term risk of stent thrombosis in the cancer patient. The increase in propensity for venous clotting, either as a result of the cancer itself, or especially with selected chemotherapeutic agents may be an issue after stenting and certainly early after coronary bypass surgery. Aggressive medical treatment to reduce risk factors, especially with statins is essential to stabilize the underlying coronary disease.
Collapse
Affiliation(s)
- Ronald J Krone
- Department of Medicine, Division of Cardiology, Washington University, School of Medicine, 660 S Euclid, Box 8086, St. Louis, MO 63130, USA.
| |
Collapse
|