Over 13 years, mortality declined after CABG, but not after PCI
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Among patients who underwent PCI or CABG between 2003 and 2016, risk-adjusted mortality decreased in the CABG population but not in the PCI population over time, researchers reported in JAMA Network Open.
The researchers also found that over time, performance of both procedures declined and the populations became more likely to be elderly, from a racial/ethnic minority and from a lower-income background.
“We noted a substantial decrease in the number of both PCI and CABG over time, likely because patients with stable coronary artery disease are increasingly being managed medically in light of the results of clinical trials demonstrating the effectiveness of that approach,” Mohamad Alkhouli, MD, cardiologist at Mayo Clinic, said in a press release. “There was an increase in the proportion of elderly patients (more than 85 years old), patients from racial minorities and those with lower income over the time period that we studied. Interestingly, men constituted two-thirds of the overall revascularization population, and this did not change much over time.”
Alkhouli and colleagues conducted a retrospective cohort study of 12,062,081 patients from the Nationwide Inpatient Sample who underwent PCI or CABG between 2003 and 2016, of whom 72% had PCI. In the PCI population, the mean age was 66 years and 66% were men. In the CABG population, the mean age was 65 years and 72% were men.
Changes over time
Over time, the annual PCI volume declined from 366 per 100,000 U.S. adults to 180 per 100,000 adults, and the annual CABG volume declined from 159 per 100,000 U.S. adults to 82 per 100,000 adults (P for trend < .001 for both).
In the PCI cohort, the proportion of white patients declined from 81.1% in 2003-2007 to 76.2% in 2013-2016, the proportion of those older than 85 years increased from 3% in 2003-2007 to 4.8% in 2013-2016 and the proportion of those with a household income in the lowest quartile increased from 24.7% in 2003-2007 to 29.6% in 2013-2016 (P < .001 for all), according to the researchers. Trends were similar but slightly less pronounced in the CABG cohort.
In both cohorts, prevalence of risk factors such as hypertension, hyperlipidemia and diabetes increased over time (P < .001 for all), Alkhouli and colleagues wrote.
The proportion of PCI procedures that were for MI increased over time (22.8% to 53.1%), and the same was true for CABG procedures (19.6% to 28.2%), according to the researchers.
Risk-adjusted mortality increased over time in PCI for STEMI (4.9% to 5.3%; P for trend < .001), and for unstable angina or stable ischemic heart disease (0.8% to 1%; P for trend < .001) but not for non-STEMI (1.6% to 1.6%; P for trend = .18), the researchers wrote.
However, risk-adjusted mortality declined over time in CABG, both in those with MI (all CABG, 5.6% to 3.4%; isolated CABG, 4.8% to 3%) and in those without MI (all CABG, 2.8% to 1.7%; isolated CABG, 2.1% to 1.2%; P < .001 for all), Alkhouli and colleagues wrote.
"Several important questions remain open," Alkhouli said in the release. "What can we do to further improve the outcomes of PCI, especially in the acute setting? How will the volumes and outcomes of PCI and CABG look in the next 10 years in light of the findings of the ISCHEMIA trial? I suspect more research will emerge on these topics in the next few years."
Better strategies needed
In a related editorial, Debabrata Mukherjee, MD, chair of the department of internal medicine and chief of cardiovascular medicine at Texas Tech University Health Sciences Center, wrote: “The lack of PCI mortality improvement over time and a slight increase in mortality among patients with unstable angina or stable ischemic heart disease suggests a need for the development of more effective strategies to further optimize contemporary PCI outcomes.
“In the past decade, there has been a remarkable increase in medical therapies with proven efficacy in reducing morbidity and mortality in patients with cardiovascular diseases. ... However, despite the benefits of these agents, secondary preventive therapies continue to be underused, and strategies to optimize medical therapies in all individuals with cardiovascular disease are needed to optimize outcomes. If we implement such strategies, revascularization may be rarely indicated in those with stable ischemic heart disease.” – by Erik Swain
Disclosures: The authors and Mukherjee report no relevant financial disclosures.
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