Target Vessel Revascularization in Older Patients Undergoing PCI
Background
The contemporary need for repeat revascularization in older patients after percutaneous coronary intervention (PCI) has not been well studied. Understanding repeat revascularization risk in this population may inform treatment decisions.
Methods
We analyzed patients ≥65 years old undergoing native-vessel PCI of de novo lesions from 2005 to 2009 discharged alive using linked CathPCI Registry and Medicare data. Repeat PCIs within 1 year of index procedure were identified by claims data and linked back to CathPCI Registry to identify target vessel revascularization (TVR). Surgical revascularization and PCIs not back linked to CathPCI Registry were excluded from main analyses but included in sensitivity analyses. Independent predictors of TVR after drug-eluting stent (DES) or bare-metal stent (BMS) implantation were identified by multivariable logistic regression.
Results
Among 343,173 PCI procedures, DES was used in 76.5% (n = 262,496). One-year TVR ranged from 3.3% (overall) to 7.1% (sensitivity analysis). Precatheterization and additional procedure-related TVR risk models were developed in BMS (c-indices 0.54, 0.60) and DES (c-indices 0.57, 0.60) populations. Models were well calibrated and performed similarly in important patient subgroups (female, diabetic, and older [≥75 years]). The use of DES reduced predicted TVR rates in high-risk older patients by 35.5% relative to BMS (from 6.2% to 4.0%). Among low-risk patients, the number needed to treat with DES to prevent 1 TVR was 63–112; among high-risk patients, this dropped to 28–46.
Conclusions
In contemporary clinical practice, native-vessel TVR among older patients occurs infrequently. Our prediction model identifies patients at low versus high TVR risk and may inform clinical decision making.
Despite several decades of technological innovation, restenosis after percutaneous coronary intervention (PCI) remains a challenge. Compared with bare-metal stents (BMS), drug-eluting stents (DES) are associated with significantly reduced rates of restenosis. The uptake of DES was rapid after its introduction in 2003, with DES use peaking at 90% of PCI procedures in 2005. Current rates of DES use, however, are lower, having been tempered by concerns over (1) the need for prolonged dual antiplatelet therapy, which increases the risk for bleeding, medication nonadherence, and stent thrombosis; (2) the complication of very late stent thrombosis associated with DES; and (3) higher technological cost. Consequently, there is growing interest in identifying patients for whom the risk of selective DES use may be acceptable.
Stent choice is especially important among the growing older US patient population. The past decade has witnessed a marked expansion in the use of PCI in older persons, with patients ≥65 years old now representing almost 40% of PCI procedures in the United States. However, restenosis or the need for target vessel revascularization (TVR) after PCI has not been well studied in older patients. Although some studies using Centers for Medicare & Medicaid (CMS) data have looked at overall revascularization rates, these studies did not have access to detailed clinical data, nor could they accurately determine TVR. Importantly, the use of DES in older patients is challenged by the significantly higher risk for post-PCI bleeding, particularly among those on prolonged dual antiplatelet therapies. From a financial perspective, the added costs of DES result in an overall net addition to national health care expenditures in Medicare beneficiaries. To date, studies have examined the financial impact of DES for the "average" patient but have not looked at the potential benefits and costs in low- or high-risk patient subgroups.
Using clinical and procedural data from the National Cardiovascular Data Registry CathPCI Registry linked with longitudinal data from CMS, we sought to (1) examine the overall rate of TVR after PCI, (2) identify predictors of TVR, and (3) examine the number needed to treat (NNT) for DES use in low- versus high-predicted TVR risk subgroups among patients ≥65 years old.
Abstract and Introduction
Abstract
Background
The contemporary need for repeat revascularization in older patients after percutaneous coronary intervention (PCI) has not been well studied. Understanding repeat revascularization risk in this population may inform treatment decisions.
Methods
We analyzed patients ≥65 years old undergoing native-vessel PCI of de novo lesions from 2005 to 2009 discharged alive using linked CathPCI Registry and Medicare data. Repeat PCIs within 1 year of index procedure were identified by claims data and linked back to CathPCI Registry to identify target vessel revascularization (TVR). Surgical revascularization and PCIs not back linked to CathPCI Registry were excluded from main analyses but included in sensitivity analyses. Independent predictors of TVR after drug-eluting stent (DES) or bare-metal stent (BMS) implantation were identified by multivariable logistic regression.
Results
Among 343,173 PCI procedures, DES was used in 76.5% (n = 262,496). One-year TVR ranged from 3.3% (overall) to 7.1% (sensitivity analysis). Precatheterization and additional procedure-related TVR risk models were developed in BMS (c-indices 0.54, 0.60) and DES (c-indices 0.57, 0.60) populations. Models were well calibrated and performed similarly in important patient subgroups (female, diabetic, and older [≥75 years]). The use of DES reduced predicted TVR rates in high-risk older patients by 35.5% relative to BMS (from 6.2% to 4.0%). Among low-risk patients, the number needed to treat with DES to prevent 1 TVR was 63–112; among high-risk patients, this dropped to 28–46.
Conclusions
In contemporary clinical practice, native-vessel TVR among older patients occurs infrequently. Our prediction model identifies patients at low versus high TVR risk and may inform clinical decision making.
Introduction
Despite several decades of technological innovation, restenosis after percutaneous coronary intervention (PCI) remains a challenge. Compared with bare-metal stents (BMS), drug-eluting stents (DES) are associated with significantly reduced rates of restenosis. The uptake of DES was rapid after its introduction in 2003, with DES use peaking at 90% of PCI procedures in 2005. Current rates of DES use, however, are lower, having been tempered by concerns over (1) the need for prolonged dual antiplatelet therapy, which increases the risk for bleeding, medication nonadherence, and stent thrombosis; (2) the complication of very late stent thrombosis associated with DES; and (3) higher technological cost. Consequently, there is growing interest in identifying patients for whom the risk of selective DES use may be acceptable.
Stent choice is especially important among the growing older US patient population. The past decade has witnessed a marked expansion in the use of PCI in older persons, with patients ≥65 years old now representing almost 40% of PCI procedures in the United States. However, restenosis or the need for target vessel revascularization (TVR) after PCI has not been well studied in older patients. Although some studies using Centers for Medicare & Medicaid (CMS) data have looked at overall revascularization rates, these studies did not have access to detailed clinical data, nor could they accurately determine TVR. Importantly, the use of DES in older patients is challenged by the significantly higher risk for post-PCI bleeding, particularly among those on prolonged dual antiplatelet therapies. From a financial perspective, the added costs of DES result in an overall net addition to national health care expenditures in Medicare beneficiaries. To date, studies have examined the financial impact of DES for the "average" patient but have not looked at the potential benefits and costs in low- or high-risk patient subgroups.
Using clinical and procedural data from the National Cardiovascular Data Registry CathPCI Registry linked with longitudinal data from CMS, we sought to (1) examine the overall rate of TVR after PCI, (2) identify predictors of TVR, and (3) examine the number needed to treat (NNT) for DES use in low- versus high-predicted TVR risk subgroups among patients ≥65 years old.