Cost advantages of an ad hoc angioplasty strategy

Ad hoc percutaneous coronary intervention in patients with stable coronary artery disease: A report from the National Cardiovascular Data Registry CathPCI Registry

Percutaneous coronary intervention (PCI) may be performed in the same procedure as diagnostic coronary angiography (ad hoc PCI). This study aimed to evaluate current rates of ad hoc PCI use and associated risks of adverse outcomes in patients with stable coronary artery disease (CAD).

METHODS

We identified 550,742 patients with stable CAD who underwent PCI in the National Cardiovascular Data Registry CathPCI Registry from 2009 to 2017. We compared in-hospital bleeding, acute kidney injury (AKI), and mortality between patients receiving ad hoc versus non-ad hoc PCI using logistic regression with inverse probability weighted propensity adjustment.

RESULTS

Between 2009 and 2017, 82.9% of patients underwent ad hoc PCI. Patients who did not undergo ad hoc PCI had higher prevalence of peripheral vascular disease, heart failure, chronic kidney disease, and coronary artery bypass graft. Ad hoc PCI was associated with lower bleeding risk (adjusted odds ratio [aOR] 0.83, 95% CI 0.79-0.87) but no differences in risks of AKI (aOR 0.95, 95% CI 0.90-1.00) or mortality (aOR 1.09, 95% CI 0.97-1.23) compared with non-ad hoc PCI. Ad hoc PCI was associated with AKI risk in patients with glomerular filtration rate <30 mL/min (interaction P < .001), mortality risk in multivessel PCI (interaction P = .031), and risks of AKI and mortality in PCI of chronic total occlusions (interaction P = .045 and .002, respectively).

CONCLUSIONS

Ad hoc PCI is extremely common among US patients with stable CAD and is associated with lower bleeding risk but no differences in risks of AKI or mortality compared with non-ad hoc PCI.

Ad hoc vs. Non-ad hoc Percutaneous Coronary Intervention Strategies in Patients With Stable Coronary Artery Disease

BACKGROUND

Few studies have evaluated the prevalence and clinical outcomes of ad hoc percutaneous coronary intervention (PCI), performing diagnostic coronary angiography and PCI in the same session, in stable coronary artery disease (CAD) patients.Methods and Results:From the CREDO-Kyoto PCI/CABG registry cohort-2, 6,943 patients were analyzed as having stable CAD and undergoing first PCI. Ad hoc PCI and non-ad hoc PCI were performed in 1,722 (24.8%) and 5,221 (75.1%) patients, respectively. The cumulative 5-year incidence and adjusted risk for all-cause death were not significantly different between the 2 groups (15% vs. 15%, P=0.53; hazard ratio: 1.15, 95% confidence interval: 0.98-1.35, P=0.08). Ad hoc PCI relative to non-ad hoc PCI was associated with neutral risk for myocardial infarction, any coronary revascularization, and bleeding, but was associated with a trend towards lower risk for stroke (hazard ratio: 0.78, 95% confidence interval: 0.60-1.02, P=0.06).

CONCLUSIONS

Ad hoc PCI in stable CAD patients was associated with at least comparable 5-year clinical outcomes as with non-ad hoc PCI. Considering patients' preference and the cost-saving, the ad hoc PCI strategy might be a safe and attractive option for patients with stable CAD, although the prevalence of ad hoc PCI was low in the current study population.

Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry

IMPORTANCE

Diagnostic coronary angiography in asymptomatic patients may lead to inappropriate percutaneous coronary intervention (PCI) due to a diagnostic-therapeutic cascade. Understanding the association between patient selection for coronary angiography and PCI appropriateness may inform strategies to minimize inappropriate procedures.

OBJECTIVE

To determine if hospitals that frequently perform coronary angiography in asymptomatic patients, a clinical scenario in which the benefit of angiography is less clear, are more likely to perform inappropriate PCI.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter observational study of 544 hospitals participating in the CathPCI Registry between July 1, 2009, and September 30, 2013.

MAIN OUTCOMES AND MEASURES

Hospital proportion of asymptomatic patients at diagnostic coronary angiography and hospital rate of inappropriate PCI as defined by 2012 appropriate use criteria for coronary revascularization.

RESULTS

Of 1 225 562 patients who underwent elective coronary angiography, 308 083 (25.1%) were asymptomatic. The hospital proportion of angiography among asymptomatic patients ranged from 1.0% to 73.6% (median, 24.7%; interquartile range, 15.9%-35.9%). By hospital quartile of asymptomatic patients at angiography, hospitals with higher rates of asymptomatic patients at angiography had higher median rates of inappropriate PCI (14.8% vs 20.2% vs 24.0 vs 29.4% from lowest to highest quartile, P < .001 for trend). This outcome was attributable to more frequent use of inappropriate PCI in asymptomatic patients at hospitals with higher rates of angiography in asymptomatic patients (5.4% vs 9.9% vs 14.7% vs 21.6% from lowest to highest quartile, P < .001 for trend). Hospitals with higher rates of asymptomatic patients at angiography also had lower rates of appropriate PCI (38.7% vs 33.0% vs 32.3% vs 32.9% from lowest to highest quartile, P < .001 for trend).

CONCLUSIONS AND RELEVANCE

In a national sample of hospitals, performance of coronary angiography in asymptomatic patients was associated with higher rates of inappropriate PCI and lower rates of appropriate PCI. Improving preprocedural risk stratification and thresholds for coronary angiography may be one strategy to improve the appropriateness of PCI.

Should interventional cardiac catheterization procedures take place at the time of diagnostic procedures?

BACKGROUND

In many cardiac catheterization laboratories interventional procedures are performed at a date later than the diagnostic study, causing increased hospital days and costs. Few data exist which compare procedural success, complications, and costs between procedures performed at the time of diagnostic study and those performed later.

HYPOTHESIS

The purpose of this study was to evaluate the safety and success of same-day interventional procedures and to quantitate hospital cost savings with this strategy.

METHOD

In all, 357 consecutive patients who underwent an elective interventional procedure of a native coronary artery either at the time of diagnostic study (same day, n = 244) or later (delayed, n = 113) were reviewed. Procedural success [< 30% residual lesion post-percutaneous transluminal coronary angioplasty (PTCA) or 0% residual lesion post-stent], major complications [death, emergent coronary artery bypass grafting (CABG), myocardial infarction, and ventricular fibrillation], hospital days, and costs were analyzed. Procedural expense, including the diagnostic and interventional procedure in the cardiac catheterization laboratory, and hospital expense were analyzed.

RESULTS

Both groups were similar in terms of age, gender, coronary risk factors, indications (myocardial infarction, unstable angina, abnormal stress test), the culprit coronary artery, type of intervention (PTCA, stent), and lesion complexity (type A, B, C). The average hospital stay for the two groups was 4.37 +/- 2 and 6.55 +/- 2.4 days, respectively (p < 0.0001). The procedural charges were $8,207.99 and 10,581.87, respectively (p < 0.0001).

CONCLUSION

Catheter intervention performed at the same time as the diagnostic cardiac catheterization procedure is as successful and as safe as that performed at a later date. Hospital stay and costs, as well as procedural expenses are significantly reduced by this practice.

Ad Hoc percutaneous coronary interventions in patients with stable coronary artery disease—A study of prevalence, safety, and variation in use from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR®)

OBJECTIVE

To utilize the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) to monitor the performance and safety of ad hoc PCIs.

BACKGROUND

The performance of ad hoc PCI remains controversial. Patients' preference, cost, and vascular access issues favor an ad hoc strategy. Adequate time for thoughtful decision-making, scheduling complexity, informed consent, and physician reimbursement favor PCI on a subsequent day.

METHODS

We analyzed results in 68,528 patients with stable angina entered in the ACC-NCDR from 2001-2003. Ad hoc PCI was evaluated in many clinical and nonclinical subgroups. A multivariable analysis was performed to determine whether ad hoc PCI had an independent relationship with complications or procedure success.

RESULTS

Overall, 60.6% of patients underwent ad hoc PCI. There was no difference in ad hoc PCI mortality, renal failure, or vascular complications from staged PCI. A lower percentage of patients at high vs. low risk and with vs. without renal failure underwent ad hoc PCIs (58.6% vs.63.0% and 50.7% vs. 60.9% respectively). There was wide variation in the performance of ad hoc PCIs according to payer (70.2-60.3%), hospital PCI volume (67-50.2%), hospital owner (89.7-59.6%), and geographic area (75.5-47.4%). Ad hoc PCI per se was not independently related to PCI success or complications.

CONCLUSIONS

PCI success was related to patient/lesion related factors and not to the performance of ad hoc PCIs per se. Although ad hoc PCI can be performed in more patients than at present, this strategy will never be possible in all patients at all times.

Ethics in Interventional Cardiology: Combining Coronary Intervention With Diagnostic Catheterization

As coronary intervention procedures have become more common, their performance at the time of diagnostic coronary arteriography has become more routine. Combined arteriography and coronary intervention may be slightly less costly and, for some patients, more dangerous than staged intervention. Combined intervention is appropriate in selected patients if they are well informed and it can be done safely; however, a combined strategy should not be applied to all patients.

SCAI statement on ad hoc versus the separate performance of diagnostic cardiac catheterization and coronary intervention

Coronary intervention may be combined with diagnostic cardiac catheterization or performed separately. In the early years of angioplasty, performing these procedures separately was standard practice. Gradually, ad hoc intervention (performing diagnostic angiography and coronary intervention within the same session) has become more common, largely because of its convenience for patients and efficiency for physicians. However, the safety and potential cost savings of this approach remain uncertain. Criteria for the appropriate use of ad hoc intervention have not been established. Ad hoc intervention is reasonable for many, but not appropriate for all patients and should not be considered standard therapy. This document updates an earlier review of this topic and provides suggestions for the use of ad hoc intervention as a routine strategy.

Ad hoc transradial coronary angioplasty strategy: experience and results in a single centre

BACKGROUND

The combination of diagnostic and angioplasty as a single procedure is becoming common practice in many institutions, but the feasibility of this strategy performed with the transradial approach in a large group of patients has not been evaluated. This study was performed to explore the feasibility, safety and cost-effectiveness of the transradial approach as a single procedure for diagnostic angiography and angioplasty, including stent implantation.

METHODS

From February 1999 and November 2000 the percutaneous transradial approach was attempted in 800 patients with functional radial arch attested using Allen's test. Interventional procedures, PTCA and stent implantation, when indicated and appropriated, have been performed as a single procedure.

RESULTS

Out of 800 patients submitted to coronarography, 390 were treated with PTCA and or stent implantation as single procedure. In this group of patients, 425 lesions (1.2 lesions/patient) were treated. A PTCA was performed in 98 (23.5%) lesions and PTCA plus stent implantation were performed in 327 (76.5%) lesions. Procedural success was achieved in 419/425 lesions (98.5%) in the radial group and in 98% in the staged group. The mean time to place the sheath was longer in the transradial group (P<0.01), but the time required to obtain hemostasis was markedly shorter in the transradial patients (P<0.01); no differences in fluoroscopy time, contrast volume and catheters per case was found. Access site bleeding complications were significantly reduced in the radial group (P<0.01) and total hospital length of stay was lesser in the radial group (mean days 1.9) as compared to femoral group (mean days 2.9) with a reduction of total hospital charge. The reduction of costs for 100 patients was Euro 78,000.

CONCLUSION

Our results show that a combined strategy of angiography and angioplasty via the radial artery is feasible, safe, more comfortable for the patient, and more cost-effective than a staged procedure. This approach might be ideal for outpatient or ad hoc invasive coronary procedures.

Safety, efficacy, and cost advantages of combined coronary angiography and angioplasty

AIM

The safety and efficacy of ad hoc PTCA has been previously reported and this approach is performed in many angioplasty centers as a routine procedure. The aim of this study is to examine whether this approach reduces the length, and cost of hospital stay.

METHODS AND RESULTS

To determine the hospital costs we studied 2,440 PTCAs over 11 years in our institution (1990-2000). Urgent PTCA for acute coronary syndromes refractory to medical treatment were excluded. In 1809 patients (74%) angioplasty was performed immediately after coronary angiography, while separate procedures were performed in 631 patients. Indication for PTCA was unstable angina in 1342 patients (55%). In the ad hoc PTCA group, 92% of the culprit lesions were successfully treated; complications included myocardial infarction (2%), urgent bypass surgery (0.6%) and death (0.9%). The rate of combined procedure progressively increased from 54% in 1990 to 88% in 2000, with a significant decrease in the rate of complications. After adjusting for clinical and angiographic differences between combined and separate procedures, angiographic success and complication rates were not statistically different in the two groups. Mean length of hospital stay decreased all along the years, and was 45% less in the ad hoc PTCA group (11.4 +/- 6.9 vs 18.2 +/- 7.7 in 1990, 5.4 +/- 4.3 vs 10.8 +/- 5.7 in 2000, P < 0.0001). The cost was 40% lower in the ad hoc PTCA group. For patients with stable angina, the savings were 49%, and for those with unstable angina, they were 29%.

CONCLUSION

In the era of coronary stenting, ad hoc PTCA can be performed in most of the patients as safely and successfully as a separate procedure. It reduces the length, and the cost of hospital stay in patients with stable or unstable angina.

"Ischemia-guided" versus "early invasive" strategies in the management of acute coronary syndrome/non-ST-segment elevation myocardial infarction: the interventionalist's perspective

Conventional therapy for non-ST-segment elevation acute coronary syndrome (ACS) has traditionally employed an "ischemia-guided" strategy. In this approach, diagnostic cardiac catheterization and revascularization are only used in patients with objective evidence of myocardial ischemia as identified by recurrent symptoms or provocative stress testing. More recent studies, however, have demonstrated improved clinical outcomes with the use of an "early invasive" approach, employing routine coronary angiography early in the patient's hospital course, followed by percutaneous intervention or bypass surgery where appropriate. Improved clinical outcomes associated with an "early invasive" strategy may have evolved as a consequence of recent advances in both adjunctive pharmacotherapy and revascularization technique. In particular, use of glycoprotein IIb/IIIa inhibitors and/or low-molecular-weight heparin before catheterization have been shown to reduce clinical events in patients with ACS, and may reduce the risk of an invasive approach by plaque passivation before interventional therapy. Perhaps more importantly, the combined use of glycoprotein IIb/IIIa inhibitors and intracoronary stenting may reduce the potential early hazard of an invasive approach by specifically decreasing the incidence of death and nonfatal myocardial infarction associated with percutaneous intervention. In spite of the benefits of this synergistic combination of pharmacology and mechanical revascularization, risk stratification remains important in identifying high-risk individuals most likely to benefit from an "early invasive" approach. In addition, angiography with possible percutaneous coronary intervention of "culprit" lesions should always be used in combination with aggressive medical therapy to treat the widespread coronary atherosclerosis commonly seen in patients with ACS.

Clinical and economic outcomes of multivessel coronary stenting compared with bypass surgery: a single-center US experience

BACKGROUND

Randomized trials comparing multivessel stenting with coronary artery bypass surgery (CABG) have demonstrated similar rates of death and myocardial infarction but higher rates of repeat revascularization after stenting. The impact of these alternative strategies on overall medical care costs is uncertain, particularly within the US health care system.

METHODS

We performed a retrospective, matched cohort study to compare the clinical and economic outcomes of multivessel stenting and bypass surgery. The stent group consisted of 100 consecutive patients who underwent stenting of >or=2 major native coronary arteries at our institution. The CABG group consisted of 200 patients who underwent nonemergent isolated bypass surgery during the same time frame, matched (2:1) for age, sex, ejection fraction, diabetes mellitus, and extent of coronary disease. Detailed clinical follow-up and resource utilization data were collected for a minimum of 2 years. Total costs were calculated by use of year 2000 unit prices.

RESULTS

Over a median follow up period of 2.8 years, there were no significant differences in all-cause mortality rates (3.0% vs 3.0%), Q-wave myocardial infarction (5.1% vs 4.0%), or the composite of death or myocardial infarction (7.1% vs 7.0%) between the stent and CABG groups (P = not significant for all comparisons). However, at 2-year follow up, patients with stents were more likely to require >or=1 repeat revascularization procedure (32.0% vs 4.5%, P <.001). The initial cost of multivessel stenting was 43% less than the cost of CABG (11,810 dollars vs 20,574 dollars, P <.001) and remained 27% less (17,634 dollars vs 24,288 dollars, P =.005) at 2 years.

CONCLUSIONS

Multivessel stenting and CABG result in comparable risks of death and myocardial infarction. Despite a higher rate of repeat revascularization, multivessel stenting was significantly less costly than CABG through the first 2 years of follow-up.

Therapeutic adjuncts for immediate transfer to the catheterization laboratory in patients with acute coronary syndromes

Early coronary intervention in patients with non-ST-segment elevation myocardial infarction (MI) and unstable angina may be made safer and more efficacious with concomitant therapies, including glycoprotein IIb/IIIa inhibitors and low-molecular-weight heparins. Stent placement has been shown to improve procedural success and reduce major in-hospital complications when compared with balloon angioplasty alone in patients with unstable angina. However, unstable angina remains a major hazard for adverse coronary events in long-term follow-up after elective stent placement. The currently available glycoprotein IIb/IIIa inhibitors-eptifibatide, tirofiban, and abciximab--have each been shown to reduce ischemic events before percutaneous coronary intervention when administered to patients presenting with non-ST-segment elevation acute coronary syndromes in large clinical trials. The adjunctive role of low-molecular-weight heparins in this scenario has been largely unexplored. Enoxaparin, when given before angiography or percutaneous coronary intervention, has been shown to be superior to unfractionated heparin in preventing major coronary events. In this review, an algorithm for treatment of non-ST-segment elevation acute coronary syndromes is presented and the current role of these newer adjunctive pharmacotherapies is explored. In the future, combinations of these agents may prove to be most beneficial in patients undergoing early percutaneous coronary intervention.

Safety and efficacy of percutaneous coronary interventions performed immediately after diagnostic catheterization in northern new england and comparison with similar procedures performed later

"Ad hoc" percutaneous coronary interventions (PCIs)-those performed immediately after diagnostic catheterization-have been reported in earlier studies to be safe with a suggestion of higher risk in certain subgroups. Despite increasing use of this strategy, no data are available in recent years with new device technology. We studied use of an ad hoc strategy in a large regional population to determine its use and outcomes compared with staged procedures. A database from the 6 centers performing PCIs in northern New England and 1 center in Massachusetts was analyzed. During 1997, excluding only patients requiring emergency procedures or those with a prior PCI, 4,136 PCIs were performed, 1,748 (42.3%) of these being ad hoc procedures. Patients having ad hoc procedures were less likely to have peripheral vascular disease, renal failure, prior myocardial infarction, or coronary artery bypass surgery, congestive heart failure, or poor left ventricular function, and more likely to have received preprocedural intravenous heparin or nitroglycerin or to have required an urgent procedure. Narrowings treated during ad hoc procedures were less frequently types B and C or in saphenous vein grafts. Adjusted rates of clinical success were not different between ad hoc and non-ad hoc procedures (93.7% vs 93.6%); there was no difference in the incidence of death (0.6% vs 0.5%), emergency (0. 9% vs 0.8%) or any (1.4% vs 0.8%) coronary artery bypass surgery, or myocardial infarction (2.6% vs 2.0%). As currently practiced in our region, ad hoc intervention is used selectively with outcomes similar for ad hoc and non-ad hoc procedures.

Ad hoc coronary intervention

Ad hoc coronary intervention is a percutaneous revascularization procedure performed at the same sitting as diagnostic cardiac catheterization. While this appears to be an efficient strategy, the safety and cost of ad hoc coronary intervention compared with delayed coronary intervention have not been clearly documented. Special preparation and precautions are necessary for patients in whom ad hoc coronary intervention is anticipated. Ad hoc coronary intervention is not appropriate if informed consent has not been previously obtained or if it would pose greater risks than delayed intervention. While ad hoc coronary intervention is often efficient and effective, its use should be individualized. Cathet. Cardiovasc. Intervent. 49:130-134, 2000.

Debate: Unstable angina - When should we intervene?

The prognosis of patients who present with non-ST segment elevation acute coronary syndromes (ACS) is guarded. These patients can be risk-stratified on the basis of symptom complex, electrocardiographic ST segment depression, obvious hemodynamic compromise and particularly on the basis of serum troponin level. An elevated troponin level determines risk and also predicts the degree of benefit from treatment with either low molecular weight heparin or platelet glycoprotein (GP) IIb/IIIa blockade. Higher risk patients should undergo early coronary angiography and myocardial revascularization as indicated and feasible. Although studies performed before the advent of coronary stenting and adjunctive platelet GP IIb/IIIa blockade suggested increased hazard for patients undergoing early intervention, recent experience cited herein supports an in-hospital and long-term clinical benefit for the aggressive approach. Here, I propose an algorithm for risk stratification and triage of appropriate patients for adjunctive pharmacotherapy and early revascularization.