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Achieving optimal results with standard balloon angioplasty: can baseline and angiographic variables predict
W J Cantor1, A S Hellkamp, E D Peterson
1St. Michael's Hospital, Toronto, Ontario, Canada. cantorw@smh.toronto.on.ca
Insights
Identifying patients who may not need stents after balloon angioplasty can significantly reduce healthcare costs. Certain clinical and angiographic factors help predict low risk for repeat revascularization, allowing for provisional stenting strategies.
Area of Science:
- Interventional Cardiology
- Cardiovascular Medicine
- Health Economics
Background:
- Coronary artery stenting reduces repeat revascularization but incurs costs and risks like in-stent restenosis.
- Identifying low-risk patients for repeat revascularization allows for selective stent use, optimizing patient benefit and resource allocation.
Purpose of the Study:
- To identify clinical and angiographic predictors of repeat revascularization after balloon angioplasty.
- To determine if a subset of patients can avoid stent implantation without compromising outcomes.
Main Methods:
- Pooled analysis of data from five interventional trials involving 5,146 patients.
- Identification of patients with optimal angiographic results (stenosis ≤30%, no dissection) post-angioplasty.
- Multivariable analysis to determine predictors of repeat revascularization.
Main Results:
- Optimal angiographic results were achieved in 18% of patients.
- Repeat revascularization rates were 20% for optimal results vs. 26% for non-optimal (p < 0.001).
- Independent predictors of repeat revascularization included female gender, lesion length ≥10 mm, and proximal LAD lesions. Patients with optimal results and none of these factors had low repeat revascularization rates (14%).
- A provisional stenting strategy could save an estimated $78 million annually in the U.S.
Conclusions:
- Baseline characteristics and angiographic results can identify low-risk patients for repeat revascularization after balloon angioplasty.
- Provisional stenting in this low-risk group can reduce costs without negatively impacting clinical outcomes.
- This approach allows for cost savings and targeted stent use in interventional cardiology.
Objectives:
To predict which patients might not require stent implantation, we identified clinical and angiographic characteristics associated with repeat revascularization after standard balloon angioplasty.
Background:
Stents reduce the risk of repeat revascularization but are costly and may lead to in-stent restenosis, which remains difficult to treat. Identification of patients at low risk for repeat revascularization may allow clinicians to reserve stents for patients most likely to benefit.
Methods:
Data from five interventional trials (5,146 patients) were pooled for analysis. We identified patients with optimal angiographic results (final diameter stenosis < or =30% and no dissection) after balloon angioplasty and determined the multivariable predictors of repeat revascularization.
Results:
Optimal angiographic results were achieved in 18% of patients after angioplasty. The repeat revascularization rate at six months was lower for patients with optimal results (20% vs. 26%, p < 0.001) but still higher than observed in stent trials. Independent predictors of repeat revascularization were female gender (odds ratio [OR] 1.67, p = 0.01), lesion length > or =10 mm (OR 1.62, p = 0.03) and proximal left anterior descending coronary artery lesions (OR 1.62, p = 0.03). For the 8% of patients with optimal angiographic results and none of these risk factors, the repeat revascularization and target vessel revascularization rates were 14% and 8% respectively, similar to rates after stent implantation. Cost analysis estimated that $78 million per year might be saved in the U.S. with a provisional stenting strategy using these criteria compared with elective stenting.
Conclusions:
A combination of baseline characteristics and angiographic results can be used to identify a small group of patients at very low risk for repeat revascularization after balloon angioplasty. Provisional stenting for these low risk patients could substantially reduce costs without compromising clinical outcomes.
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