Thirty-year trends in outcomes of percutaneous coronary interventions in diabetic patients

Sex Differences in Long-Term Cause-Specific Mortality After Percutaneous Coronary Intervention: Temporal Trends and Mechanisms

BACKGROUND

Women have higher rates of all-cause mortality after percutaneous coronary intervention. Whether this is because of greater age and comorbidity burden or a sex-specific factor remains unclear.

METHODS AND RESULTS

We retrospectively assessed cause-specific long-term mortality after index percutaneous coronary intervention over 3 time periods (1991-1997, 1998-2005, and 2006-2012). Cause of death was determined using telephone interviews, medical records, and death certificates. We performed competing risks analyses of cause-specific mortality. A total of 6847 women and 16 280 men survived index percutaneous coronary intervention hospitalization 1991 to 2012. Women were older (mean±SD: 69.4±12 versus 64.8±11.7 years; P<0.001) with more comorbidities (mean±SD: Charlson index 2.1±2.1 versus 1.9±2.1; P<0.001). Across the 3 time periods, both sexes exhibited a decline in cardiac deaths at 5 years (26% relative decrease in women, 17% in men, trend P<0.001 for each). Although women had higher all-cause mortality compared with men in all eras, the excess mortality was because of noncardiac deaths. In the contemporary era, only a minority of deaths were cardiac (33.8% in women, 38.0% in men). After adjustment, there was no evidence for a sex-specific excess of risk for cardiac or noncardiac mortality. The commonest causes of death were chronic diseases and heart failure in women (5-year cumulative mortality, 5.4% and 3.9%) but cancer and myocardial infarction/sudden death in men (5.4% and 4.3%).

CONCLUSIONS

The higher mortality after percutaneous coronary intervention in women is because of death from noncardiac causes. This is accounted for by baseline age and comorbidities rather than an additional sex-specific factor. These findings have implications for sex-specific clinical care and trial design.

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.

Prognosis of primary percutaneous coronary intervention in elderly patients with ST-elevation myocardial infarction

Objective

To evaluate the prognosis of primary percutaneous coronary intervention (PPCI) and medical therapy (MT) in elderly patients presenting with ST-elevation myocardial infarction (STEMI).

Methods

A total of 238 STEMI patients aged above 80 and treated with PPCI (n = 186) and MT (n = 52) at Harefield Hospital, London were included in this study. Patients who did not have true STEMI based on non-diagnostic electrocardiogram (ECG) for STEMI and negative troponin, who presented with left bundle branch block (LBBB) and had normal coronaries were excluded from this study. Primary PCI was defined as any use of a guidewire for more than diagnostic purposes in patients with STEMI, whereas conventional MT was defined as treatment of patients with anti-platelets and anti-thrombotic medications without thrombolysis.

Results

The survival rate of PPCI patients was 86% (n = 160) at month 1 followed by 83.9% (n = 156) at month 6, and 81.2% (n = 151) at month 12. The survival rate of MT patients was 44.2% (n = 23) at month 1 followed by 36.5% (n = 19) at month 6, and 34.6% (n = 18) at month 12. Compared to MT, significantly fewer comorbidities were found in the PPCI group. Ventricular fibrillation (VF) (4.8%) and consequent admission to intensive care unit (7%) were the major complications of the PPCI group.

Conclusion

PPCI has a higher survival rate and, compared to MT, fewer comorbidities were observed in the PPCI group of elderly patients presenting with STEMI.

Trends in cause of death after percutaneous coronary intervention

BACKGROUND

The impact of changing demographics on causes of long-term death after percutaneous coronary intervention (PCI) remains incompletely defined.

METHODS AND RESULTS

We evaluated trends in cause-specific long-term mortality after index PCI performed at a single center from 1991 to 2008. Deaths were ascertained by scheduled prospective surveillance. Cause was determined via telephone interviews, medical records, autopsy reports, and death certificates. Competing-risks analysis of cause-specific mortality was performed using 3 time periods of PCI (1991-1996, 1997-2002, and 2003-2008). Final follow-up was December 31, 2012. A total of 19 077 patients survived index PCI hospitalization, of whom 6988 subsequently died (37%, 4.48 per 100 person-years). Cause was determined in 6857 (98.1%). Across 3 time periods, there was a 33% decline in cardiac deaths at 5 years after PCI (incidence: 9.8%, 7.4%, and 6.6%) but a 57% increase in noncardiac deaths (7.1%, 8.5%, and 11.2%). Only 36.8% of deaths in the recent era were cardiac. Similar trends were observed regardless of age, extent of coronary disease, or PCI indication. After adjustment for baseline variables, there was a 50% temporal decline in cardiac mortality but no change in noncardiac mortality. The decline in cardiac mortality was driven by fewer deaths from myocardial infarction/sudden death (P<0.001) but not heart failure (P=0.85). The increase in noncardiac mortality was primarily attributable to cancer and chronic diseases (P<0.001).

CONCLUSIONS

This study found a marked temporal switch from predominantly cardiac to predominantly noncardiac causes of death after PCI over 2 decades. The decline in cardiac mortality was independent of changes in baseline clinical characteristics. These findings have implications for patient care and clinical trial design.

National trends over one decade in hospitalization for acute myocardial infarction among Spanish adults with type 2 diabetes: cumulative incidence, outcomes and use of percutaneous coronary intervention

BACKGROUND

This study aims to describe trends in the rate of acute myocardial infarction (AMI) and use of percutaneous coronary interventions (PCI) in patients with and without type 2 diabetes in Spain, 2001-2010.

METHODS

We selected all patients with a discharge of AMI using national hospital discharge data. Discharges were grouped by diabetes status: type 2 diabetes and no diabetes. In both groups PCIs were identified. The cumulative incidence of discharges attributed to AMI were calculated overall and stratified by diabetes status and year. We calculated length of stay and in-hospital mortality (IHM). Use of PCI was calculated stratified by diabetes status. Multivariate analysis was adjusted by age, sex, year and comorbidity.

RESULTS

From 2001 to 2010, 513,517 discharges with AMI were identified (30.3% with type 2 diabetes). The cumulative incidence of discharges due to AMI in diabetics patients increased (56.3 in 2001 to 71 cases per 100,000 in 2004), then decreased to 61.9 in 2010. Diabetic patients had significantly higher IHM (OR, 1.14; 95%CI, 1.05-1.17). The proportion of diabetic patients that underwent PCI increased from 11.9% in 2001 to 41.6% in 2010. Adjusted incidence of discharge in patients with diabetes who underwent PCI increased significantly (IRR, 3.49; 95%CI, 3.30-3.69). The IHM among diabetics patients who underwent a PCI did not change significantly over time.

CONCLUSIONS

AMI hospitalization rates increased initially but declining slowly. From 2001 to 2010 the proportion of diabetic patients who undergo a PCI increased almost four-fold. Older age and more comorbidity may explain why IHM did not improve after a PCI.

The growing prevalence of type 2 diabetes: increased incidence or improved survival?

Approximately 347 million persons were estimated to have diabetes worldwide in 2008, an increase of 194 million cases from 1980. Diabetes now affects both high- and low-income countries, with low-income countries bearing the majority of the burden. The epidemiologic transition from traditional health risks, such as poor hygiene, to modern health risks, such as sedentary lifestyle, has facilitated the increase in incidence in diabetes, especially in developing countries. The effect of these risk factors may be especially pronounced in some racial and ethnic populations. Increased surveillance for diabetes has contributed to increased diabetes prevalence in higher-income countries. Survival with and some risk factors for diabetes have improved in developed countries, but global diabetes mortality has increased by 20 % since 1990. Population growth and aging will only increase the burden of diabetes, and public health interventions are needed to address diabetes risk factors to stem the tide of this epidemic.