Three-year survival after percutaneous coronary intervention according to appropriateness criteria for
Sorin J Brener1, Salman A Haq, Sanjay Bose
1NY Methodist Hospital, Division of Cardiology, Brooklyn, NY 11215, USA. sjb9005@nyp.org
Insights
Percutaneous coronary intervention (PCI) outcomes were favorable for appropriate and uncertain indications. Appropriateness criteria alone may not fully guide revascularization decisions in coronary artery disease (CAD).
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Outcomes Research
Background:
- Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) choice remains debated for many patients.
- Numerous trials and meta-analyses have not definitively resolved revascularization strategy in coronary artery disease (CAD).
Purpose of the Study:
- To compare 3-year outcomes of PCI based on established appropriateness criteria.
- To evaluate the impact of PCI indication (appropriate, uncertain, inappropriate) on patient survival.
Main Methods:
- A consecutive cohort of 2,134 patients undergoing their first PCI without prior CABG or emergency indication were analyzed.
- Patients were categorized into 'Appropriate' (1-2 vessel CAD), 'Uncertain' (3-vessel CAD), and 'Inappropriate' (left main stenosis) based on indication.
- Survival was tracked using the Social Security Death Index.
Main Results:
- The majority of PCIs were classified as 'appropriate' (80%), followed by 'uncertain' (19.4%) and 'inappropriate' (0.6%).
- In-hospital complication rates were low across all groups (≥98.6%).
- Estimated 900-day survival was high for 'appropriate' (92.6%) and 'uncertain' (91.3%) groups, but significantly lower for the 'inappropriate' group (66.9%; p=0.014). Advanced age and comorbidities, not appropriateness, predicted mortality.
Conclusions:
- Most PCIs performed align with 'appropriate' indications.
- 'Uncertain' PCI cases demonstrated outcomes comparable to 'appropriate' cases during hospitalization and 3-year follow-up.
- Current anatomically-based appropriateness criteria may be insufficient for guiding the choice of revascularization strategy.
Objectives:
We sought to compare 3-year outcomes of percutaneous coronary intervention (PCI) according to recently published appropriateness criteria for PCI.
Background:
The choice of revascularization between PCI and coronary artery bypass grafting (CABG) remains uncertain in many patients despite numerous randomized clinical trials and meta-analyses.
Methods:
Consecutive patients undergoing a first PCI at a single, large-volume institution were included if they did not have prior CABG and did not need emergency PCI. Patients were classified according to PCI indication into the following groups: Appropriate (A) - 1- or 2-vessel coronary artery disease (CAD), Uncertain (U) - 3-vessel CAD and Inappropriate (I) - left main coronary artery stenosis. Survival was assessed with the Social Security Death Index.
Results:
A total of 2,134 patients fulfilled the study criteria: 1,706 (80%) with "appropriate" PCI, 414 (19.4%) with "uncertain" PCI and only 14 (0.6%) with "inappropriate" PCI. In-hospital outcomes were very favorable, with 99.3%, 98.6% and 100% of the three groups, respectively, experiencing no complications (p = 0.31). The estimated survival in the three categories at 900 days was 92.6% (95% confidence interval 91-94%) for Group A, 91.3% (88-4%) for Group U and 66.9% (33-87%) for Group I; p = 0.014. The only predictors of mortality were advanced age and comorbidities, but not "appropriateness level" (p = 0.26).
Conclusion:
The majority of PCIs performed would were classified as "appropriate." The patients classified as "uncertain" had similarly favorable outcomes, as those considered "appropriate" both during initial hospitalization and during the 3-year follow up. If confirmed, these data suggest that anatomically-based appropriateness criteria are not sufficient to inform choice of revascularization method.
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