Coronary artery bypass graft surgery trends in New South Wales, Australia

Trends and Outcomes for Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in New South Wales from 2008 to 2019

Risk profiles are changing for patients who undergo percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). In Australia, little is known of the nature of these changes in contemporary practice and of the impact on patient outcomes. We identified all CABG (n = 40,805) and PCI (n = 142,399) procedures in patients aged ≥18 years in New South Wales, Australia, during 2008 to 2019. Between 2008 and 2019, the age- and gender-standardized revascularization rate increased by 20% (from 267/100,000 to 320/100,000 population) for all revascularizations. The increase in revascularization was particularly driven by a 35% increase (from 194/100,000 to 261/100,000) in PCI, whereas the rate of CABG decreased by 20% (from 73/100,000 to 59/100,000). Mean age and the prevalence of co-morbidities (especially diabetes and atrial fibrillation) increased for patients with PCI in more recent years but remained consistently lower than for patients with CABG. CABGs performed in patients presenting with a non-ST-segment-elevation acute coronary syndrome halved from 34.3% to 18.7% during the study period, whereas PCIs in this group decreased from 36.5% to 29.6%. Risk-adjusted in-hospital mortality decreased by 7.5 deaths/1,000 procedures per month for CABG but remained unchanged for PCI. Risk-adjusted readmission rates were consistently higher for CABG than for PCI and did not change significantly over time. In conclusion, we observed a dramatic shift over time from CABG to PCI as the revascularization procedure of choice, with the patient base for PCI extending to older and sicker patients. There was a large decrease in mortality after CABG, whereas mortality after PCI remained unchanged.

Effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery: a systematic review

REVIEW OBJECTIVE

The objective of this review was to investigate the effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery on patients' health-related quality of life and hospital readmission.

INTRODUCTION

Coronary heart disease is a major cause of death and disability worldwide, putting a great strain on healthcare resources. For the past two decades, population-wide primary prevention and individual healthcare approaches have resulted in a dramatic decline in overall cardiac mortality. Over the intervening years, surgical techniques in cardiology have also improved substantially. As a result, long-term outcomes in patients treated with coronary artery bypass graft surgery have established the treatment's effectiveness and survival benefit. Furthermore, participating in cardiac rehabilitation following coronary artery bypass graft surgery has also demonstrated a significant decrease in all-cause cardiac mortality in these patients.

INCLUSION CRITERIA

This review included studies with participants aged 18 years and over, post coronary artery bypass graft surgery that evaluated nurse-led cardiac rehabilitation (CR) programs compared with usual care or other forms of CR. The outcomes of interest were the health-related quality of life and hospital readmissions following coronary artery bypass graft surgery and measured using validated scales. Randomized controlled trials reported in English between 2000 to June 2017 were considered for inclusion.

METHODS

The search strategy aimed to find both published and unpublished studies using a three-step search strategy. An initial search of MEDLINE, CINAHL and Scopus was undertaken, followed by a search for unpublished studies including Dissertation Abstracts International, ProQuest Dissertations and Theses, Google Scholar, MedNar and ClinicalTrials.gov. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal tools from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Quantitative data was extracted from papers included in the review using the standardized data extraction tool from JBI-SUMARI. No meta-analysis was undertaken due to heterogeneity of the outcome measures. All results were subject to double data entry. Effect sizes expressed as risk ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis.

RESULTS

Three trials involving 329 patients were included in the final review. The trials that investigated the effect of home based cardiac rehabilitation programs compared to usual care at six weeks, three months and six months follow-up demonstrated no statistically significant difference in health-related quality of life at any of the follow-up periods. However, one study demonstrated significantly higher scores related to health-related quality of life among those who received nurse-led home based cardiac rehabilitation (154.93 ± 4.6) compared to those who received usual care (134.20 ± 8.2) at two months follow-up. No trials were identified that compared the effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery on readmissions to hospital.

CONCLUSION

There is not enough evidence to support or discourage nurse-led cardiac rehabilitation programs on health-related quality of life in patients following coronary artery bypass graft surgery. However, the sparse data available suggests improvements in health-related quality of life at two months follow-up among those who received a nurse-led program. Further large-scale multicenter trials with standardized methodology are needed to determine the effect of nurse-led cardiac rehabilitation programs on health-related quality of life and rates of readmission to hospital following coronary artery bypass graft surgery.

Current trends in coronary revascularization

The options for coronary revascularization broadened in recent years with the introduction of bare-metal stents in the 1990s and drug-eluting stents in 2003. Since then, the rates of percutaneous coronary intervention (PCI) have increased whereas the use of coronary artery bypass grafting (CABG) has decreased. Although historically there have been disparities in the use of revascularization procedures in women, the elderly, and nonwhite patients, there is some evidence to suggest these gaps have narrowed in recent years. In any given clinical circumstance, there is ongoing debate as to whether PCI or CABG is the more appropriate revascularization method depending on coronary anatomy, ventricular function, and associated conditions. Also, trends in coronary revascularization are potentially influenced by emerging clinical evidence and new technologies, national guidelines and appropriateness criteria, procedure reimbursement, and changes in the population being treated. Accordingly, it is unclear whether the trend in increased use of PCI versus CABG will continue.

Trends in percutaneous coronary interventions in new South Wales, Australia

This is the first detailed study on percutaneous coronary intervention (PCI) in New South Wales (NSW), Australia. Hospital data for PCIs carried out between 1 July 1990 and 30 June 2002 are analysed. The study explores trends in PCI rates by selected socio-demographic factors, the utilisation of angioplasties vis-a-vis stents, emergency admissions, and selected coexisting conditions which determine the disease status of PCI patients. Logistic regression models are used to study the medical conditions that require both PCI and coronary artery bypass graft (CABG). The PCI rate has grown rapidly at 12.1% per annum, with a particularly rapid increase for persons aged 75+. The rate of multiple stent utilisation increased at 4.6% per annum. Pacific-born and Middle-Eastern-born patients are more than twice as likely as the Australian-born to have diabetes. Factors affecting failure of PCI requiring CABG include perforation and multi-vessel disease. PCI services in public hospitals need to be increased to facilitate the availability of these procedures to all segments of the population, as do targeted community-level programmes to educate high-risk groups in the control of heart diseases.