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Contemporary Management Before Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From the
Stanley A Swat1, Annika Hebbe2, Mary E Plomondon3
1Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO (S.A.S., R.S.B., S.W.W., J.A.V.).
Insights
Less than half of patients received guideline-recommended antianginal therapy and stress testing before coronary artery chronic total occlusion percutaneous coronary intervention. Significant variability exists across healthcare sites and operators, indicating a need for improved management consistency.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Services Research
Background:
- Clinical guidelines recommend maximal antianginal medical therapy before coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
- The extent of adherence to these guidelines in current clinical practice is not well-established.
- This study investigates the utilization of pre-procedural antianginal therapy and stress testing for CTO PCI within a national healthcare system.
Purpose of the Study:
- To assess the frequency of guideline-recommended antianginal therapy and stress testing prior to CTO PCI.
- To evaluate the variability in the application of pre-procedural management strategies across different healthcare sites and operators.
- To identify potential areas for improvement in patient management before CTO PCI.
Main Methods:
- Retrospective analysis of patients undergoing attempted CTO PCI from 2012 to 2018 in the Veterans Affairs Healthcare System.
- Categorization of patients based on pre-procedural management: use of ≥2 antianginal medications and/or stress testing within 3 months of PCI.
- Statistical analysis using multivariable logistic regression and inverse propensity weighting, with median odds ratios (MOR) to quantify variability.
Main Results:
- Among 4250 patients, only 40% received ≥2 antianginal medications and 24% underwent stress testing before CTO PCI.
- No significant temporal trends were observed in the use of ≥2 antianginals or combined therapy, but pre-procedural stress testing decreased over time.
- Substantial variability in both antianginal therapy (MOR=1.3-1.35) and stress testing (MOR=1.68-1.80) was noted across hospital sites and operators.
Conclusions:
- A significant proportion of patients undergoing CTO PCI do not receive guideline-recommended pre-procedural management.
- Considerable variability in care delivery exists at both institutional and individual operator levels.
- Standardizing management protocols before CTO PCI could enhance the quality of care and potentially improve patient outcomes.
Background:
Guidelines recommend maximal antianginal medical therapy before attempted coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The degree to which this occurs in contemporary practice is unknown. We aimed to characterize the frequency and variability of preprocedural use of antianginal therapy and stress testing within 3 months before PCI of CTO (CTO PCI) across a nationally integrated health care system.
Methods:
We identified patients who underwent attempted CTO PCI from January 2012 to September 2018 within the Veterans Affairs Healthcare System. Patients were categorized by management before CTO PCI: presence of ≥2 antianginals, stress testing, and ≥2 antianginals and stress testing within 3 months of PCI attempt. Multivariable logistic regression and inverse propensity weighting were used for adjustment before trimming, with median odds ratios calculated for variability estimates.
Results:
Among 4250 patients undergoing attempted CTO PCI, 40% received ≥2 antianginal medications and 24% underwent preprocedural stress testing. The odds of antianginal therapy with more than one medication before CTO PCI did not change over the years of the study (odds ratio [OR], 1.0 [95% CI, 0.97-1.04]), whereas the odds of undergoing preprocedural stress testing decreased (OR, 0.97 [95% CI, 0.93-0.99]), and the odds of antianginal therapy with ≥2 antianginals and stress testing did not change (OR, 0.98 [95% CI, 0.93-1.04]). Median odds ratios (MOR) showed substantial variability in antianginal therapy across hospital sites (MOR, 1.3 [95% CI, 1.26-1.42]) and operators (MOR, 1.35 [95% CI, 1.26-1.63]). Similarly, preprocedural stress testing varied significantly by site (MOR, 1.68 [95% CI, 1.58-1.81]) and operator (MOR, 1.80 [95% CI, 1.56-2.38]).
Conclusions:
Just under half of patients received guideline-recommended management before CTO PCI, with significant site and operator variability. These findings suggest an opportunity to reduce variability in management before CTO PCI.
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