Temporal trends in relative survival following percutaneous coronary intervention

Long-term follow-up of patients with complex coronary artery disease treated with minimally invasive direct coronary artery bypass

BACKGROUND

Patients with complex coronary artery disease (CAD) may benefit from surgical myocardial revascularization but weighing the risk of peri-operative complications against the expected merit is difficult. Minimally invasive direct artery bypass (MIDCAB) procedures are less invasive, provide the prognostic advantage of operative revascularization of the left anterior descending artery and may be integrated in hybrid strategies. Herein, the outcomes between patients with coronary 1-vessel disease (1-VD) and patients with 2-VD and 3-VD after MIDCAB procedures were compared in this single-center study.

METHODS

Between 1998 and 2018, 1363 patients underwent MIDCAB at the documented institution. 628 (46.1%) patients had 1-VD, 434 (31.9%) patients 2-VD and 300 (22.0%) patients suffered from 3-VD. Data of patients with 2-VD, and 3-VD were pooled as multi-VD (MVD).

RESULTS

Patients with MVD were older (66.2 ± 10.9 vs. 62.9 ± 11.2 years; p < 0.001) and presented with a higher EuroScore II (2.10 [0.4; 34.2] vs. 1.2 [0.4; 12.1]; p < 0.001). Procedure time was longer in MVD patients (131.1 ± 50.3 min vs. 122.2 ± 34.5 min; p < 0.001). Post-operatively, MVD patients had a higher stroke rate (17 [2.3%] vs. 4 [0.6%]; p = 0.014). No difference in 30-day mortality was observed (12 [1.6%] vs. 4 [0.6%]; p = 0.128). Survival after 15 years was significantly lower in MVD patients (p < 0.01). Hybrid procedures were planned in 295 (40.2%) patients with MVD and realized in 183 (61.2%) cases. MVD patients with incomplete hybrid procedures had a significantly decreased long-term survival compared to cases with complete revascularization (p < 0.01).

CONCLUSIONS

Minimally invasive direct coronary artery bypass procedures are low-risk surgical procedures. If hybrid procedures have been planned, completion of revascularization should be a major goal.

Patient Characteristics, Procedural Details, and Outcomes of Contemporary Percutaneous Coronary Intervention in Real-World Practice: Insights from Nationwide Thai PCI Registry

Background

Percutaneous coronary intervention (PCI) practice and outcomes vary substantially in different parts of the world. The contemporary data of PCI in Asia are limited and only available from developed Asian countries.

Objectives

To explore the pattern of practice and results of PCI procedures in Thailand as well as a temporal change of PCI practice over time compared with the registry from other countries.

Methods

Thai PCI Registry is a prospective nationwide registry that was an initiative of the Cardiac Intervention Association of Thailand (CIAT). All cardiac catheterization laboratories in Thailand were invited to participate during 2018-2019, and consecutive PCI patients were enrolled and followed up for 1 year. Patient baseline characteristics, procedural details, equipment and medication use, outcomes, and complications were recorded.

Results

Among the 39 hospitals participated, there were 22,741 patients included in this registry. Their mean age (standard deviation) was 64.2 (11.7) years and about 70% were males. The most common presentation was acute coronary syndrome (57%) with a high proportion of ST-elevation myocardial infarction (28%). Nearly two-thirds of patients had multivessel disease and significant left main stenosis was reported in 11%. The transradial approach was used in 44.2%. The procedural success rate was very high (95.2%) despite the high complexity of the lesions (56.9% type C lesion). The incidence of procedural complications was 5.3% and in-hospital mortality was 2.8%.

Conclusion

Thai PCI Registry provides further insights into the current practice and outcomes of PCI in Southeast Asia. The success rate was very high, and the complications were very low despite the high complexity of the treated lesions.

Ten-year trends of clinical outcomes after percutaneous coronary intervention: a Korean nationwide longitudinal cohort study

OBJECTIVES

Mortality following percutaneous coronary intervention (PCI) is a key quality measurement in clinical practice. This study investigated the 10-year trends of mortality following PCI in an unselected nationwide cohort.

DESIGN

Retrospective cohort study.

SETTING

A nationwide study in South Korea.

PARTICIPANTS

PCI claim data from 2006 to 2015 of the National Health Insurance Service and the Statistics of Korea.

MEASURES

1-year cardiovascular or non-cardiovascular death.

RESULTS

In total, 437 436 patients were included. The annual number of PCI cases increased from 32 098 to 51 990 over the decade studied (p<0.001). Patients were divided into quartile subgroups according to an estimated adjusted probability for predicting 1-year all-cause death. The proportion of patients in the high-risk quartiles increased whereas those in the low-risk quartiles decreased (p<0.001). The 1-year cumulative incidence rate of all-cause death did not change in the population with risk scores in the 1st (0.9% to 0.8%) and 2nd (1.3% to 1.3%) quartiles, whereas it increased in the population with risk scores in the 3rd (3.4% to 5.1%) and 4th (15.5% to 19.4%) quartiles (p<0.001). Compared with year 2006, the mean survival time in year 2015 was shorter by 0, 3.3 and 12.4 days in patients with risk scores in the 1st or 2nd, 3rd and 4th quartiles, respectively. These findings were also consistent for cardiovascular or non-cardiovascular deaths.

CONCLUSION

The number, proportion and the overall risk of patients with a high risk for mortality after PCI increased over the decade in Korea.

One-year outcome after percutaneous coronary intervention in nonagenarians: Insights from the J-PCI OUTCOME registry

BACKGROUND

Nonagenarian patients who undergo percutaneous coronary intervention (PCI) are increasing, and a few previous studies have reported their long-term outcomes. However, differences in their long-term outcomes between generations remain unclear. This study aimed to investigate 1-year all-cause and cardiovascular (CV) mortality, and major adverse cardiovascular events (MACE; cardiovascular death, myocardial infarction, and stroke) of nonagenarian patients who underwent PCI compared with the other elder patients, using a nationwide registration system.

METHODS

The patient-level data registered between January 2017 and December 2017 was extracted from the J-PCI OUTCOME Registry endorsed by the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT). The one-year all-cause and cardiovascular (CV) mortality, MACE, and major bleeding events were identified.

RESULTS

Out of 40,722 patients over 60 years of age, 880 (2.1%) were nonagenarians. For nonagenarians, the 1-year mortality rate was substantial (13.5%). The MACE and CV death rates were also high (8.1%, and 6.8%, respectively) for nonagenarians, and these event rates were approximately 1.5 times higher in nonagenarians than octogenarians. Multivariate regression analysis showed that presentation with cardiogenic shock [hazard ratio (HR) 2.32; 95 confidence intervals (CI): 1.22-4.41], or cardiac arrest (HR 2.91; 90% CI: 1.28-6.62), and use of oral anticoagulants (HR 2.10; 90% CI: 1.07-4.12) were the predictors of 1-year MACE.

CONCLUSIONS

Even in the contemporary era, nonagenarians who have undergone PCI still face a considerably increased risk for adverse cardiovascular events that reduces long-term survival. In addition to having poorer lesion characteristics, adverse events, including death, MACEs, and major bleeding, occurred 1.5 times more frequently in nonagenarians than in octogenarians.

Temporal trends in clinical outcomes after percutaneous coronary intervention: a systematic review of 66,327 patients from 25 all-comers trials

BACKGROUND

With the improvements of percutaneous coronary intervention (PCI) technology and post-PCI patient management, several registry studies reported temporal trends in post-PCI clinical outcomes. However, their results are inconclusive, potentially reflecting region-specific trends, based on site-reported events without external validity.

AIMS

This study aimed to investigate temporal trends in post-PCI clinical outcomes in all-comers randomised controlled trials (RCTs) involving coronary stents.

METHODS

We performed a systematic review identifying RCTs comparing a clinical outcome as a primary endpoint among different coronary stents with an all-comers design and independent clinical event adjudication, extracting the study start year, patient baseline characteristics, and one- and five-year clinical outcomes. Temporal trends in clinical outcomes (cardiac death, myocardial infarction [MI], target lesion revascularisation [TLR], stent thrombosis [ST]) were assessed using random-effects meta-regression analyses, estimating the relationship between clinical outcomes and study start year.

RESULTS

Overall, 25 all-comers trials (51 device arms, 66,327 patients) conducted between 2003 and 2018 fulfilled the eligibility criteria. Random-effects meta-regression analysis revealed significant decreasing trends in one- and five-year cardiac death, one-year TLR, and five-year ST incidences (relative risk per 10-year increase: 0.69 [0.51-0.92], 0.66 [0.44-0.98], 0.60 [0.41-0.88], and 0.18 [0.07-0.44], respectively). There was no significant trend in myocardial infarction incidences.

CONCLUSIONS

This is the first attempt to clarify and quantify the temporal trends of post-PCI outcome incidence. The 15-year improvements in PCI therapy and post-therapeutic patient management are associated with reduced incidences of cardiac death and PCI-related adverse events.

Estimating the economic impacts of percutaneous coronary intervention in Australia: a registry-based cost burden study

OBJECTIVES

In this study, we sought to evaluate the costs of percutaneous coronary intervention (PCI) across a variety of indications in Victoria, Australia, using a direct per-person approach, as well as to identify key cost drivers.

DESIGN

A cost-burden study of PCI in Victoria was conducted from the Australian healthcare system perspective.

SETTING

A linked dataset of patients admitted to public hospitals for PCI in Victoria was drawn from the Victorian Cardiac Outcomes Registry (VCOR) and the Victorian Admitted Episodes Dataset. Generalised linear regression modelling was used to evaluate key cost drivers. From 2014 to 2017, 20 345 consecutive PCIs undertaken in Victorian public hospitals were captured in VCOR.

PRIMARY OUTCOME MEASURES

Direct healthcare costs attributed to PCI, estimated using a casemix funding method.

RESULTS

Key cost drivers identified in the cost model included procedural complexity, patient length of stay and vascular access site. Although the total procedural cost increased from $A55 569 740 in 2014 to $A72 179 656 in 2017, mean procedural costs remained stable over time ($A12 521 in 2014 to $A12 185 in 2017) after adjustment for confounding factors. Mean procedural costs were also stable across patient indications for PCI ($A9872 for unstable angina to $A15 930 for ST-elevation myocardial infarction) after adjustment for confounding factors.

CONCLUSIONS

The overall cost burden attributed to PCIs in Victoria is rising over time. However, despite increasing procedural complexity, mean procedural costs remained stable over time which may be, in part, attributed to changes in clinical practice.

Blood Pressure and Renal Progression in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

High blood pressure (BP) may impair renal function following percutaneous coronary intervention (PCI). However, the predictability of renal progression based on admission and discharge BP and BP threshold values remains unclear.

METHODS

A total of 8,176 adult patients who underwent PCI at Seoul National University Hospital from 2006 to 2016 were retrospectively analyzed. Renal progression was defined as a doubling of serum creatinine levels, ≥50% decrease of the estimated glomerular filtration rate, or development of end-stage renal disease. The risk of renal progression according to admission BP (any time) and discharge BP (8:00-10:00 am) was evaluated by multivariable Cox and additive generalized models with penalized splines.

RESULTS

During a median follow-up of 7 years (maximum: 13 years), 9.3% of patients (n = 758) reached renal progression. BP between admission and discharge showed a low correlation, and all BP parameters showed a nonlinear relationship with renal progression. Systolic BP at discharge (SBPd) was selected as the best predictor of renal progression because the delta for the Akaike information criterion from the baseline model to the model with BP parameters was the lowest. The risk of renal progression started to increase at SBPd ≥ 125 mm Hg. This increasing risk of renal progression with SBPd ≥ 125 mm Hg remained significant, despite adjusting for the competing risk of all-cause death.

CONCLUSIONS

High SBPd is associated with renal progression following PCI, particularly when it is ≥125 mm Hg. This can be used as a risk classification and potential target of renoprotective therapies.