Abstract
BackgroundIncreasing rates of percutaneous coronary intervention (PCI) and decreasing rates of coronary artery bypass graft (CABG) surgery followed the introduction of drug eluting stents in Western Australia in 2002. We assessed the impact of these changes on one-year outcomes for the total population of patients undergoing coronary artery revascularisation procedures (CARP) in Western Australia between 2000-2004.MethodsClinical and linked administrative data (inpatient admissions and death) were merged for all patients who had their first CARP with stent or CABG in Western Australia between 2000-2004. The clinical data were collected from all hospitals in Western Australia where CARP procedures are performed. We calculated the unadjusted (Kaplan-Meier) and adjusted (Cox) risks for one-year death (all-cause), death (all-cause) or admission for myocardial infarction (MI), target vessel revascularisation (TVR) and the composite outcome of death/MI/TVR (major adverse cardiac events, MACE).ResultsOver the study period, there were 14,118 index CARPs. The use of drug eluting stents increased from 0% to 95.8% of PCI procedures, and PCI procedures increased from 61.1% to 74.4% of all CARPS. There were no temporal changes in adjusted one-year mortality or death/MI. Overall, adjusted one-year MACE fell from 11.3% in 2000 to 8.5% in 2004 (p<0.0001) due to a significant reduction in TVR in the PCI group.ConclusionThe introduction of drug eluting stents and resulting changes in coronary revascularisation strategies were not associated with changes in the one-year risk of major clinical endpoints (death or death/MI), but were associated with a significant reduction in the risk of MACE, driven entirely by a reduction in TVR after PCI. This real world study supports the effectiveness of drug eluting stents in reducing repeat procedures in the total CARP population without increasing the risk of death or MI.
Highlights
Increasing rates of percutaneous coronary intervention (PCI) and decreasing rates of coronary artery bypass graft (CABG) surgery followed the introduction of drug eluting stents in Western Australia in 2002
Bare metal stents were introduced into Western Australia in 1988 as a bailout strategy for complicated balloon angioplasty and their use increased through the early 1990s, becoming a primary strategy for PCI by the mid-1990s
This increase in bare metal stents (BMS) use was associated with a period of accelerated growth in total coronary artery revascularisation procedures (CARP) driven by an increase in PCI while there was a modest decline in rates of CABG
Summary
Increasing rates of percutaneous coronary intervention (PCI) and decreasing rates of coronary artery bypass graft (CABG) surgery followed the introduction of drug eluting stents in Western Australia in 2002. It is often difficult to assess the relative effectiveness and real-world safety of new techniques, with guidance usually coming from case series, registries and randomised controlled trials. Most of these studies examine either PCI or CABG or, in some cases, direct comparisons between different revascularisation strategies in selected populations [2,3,4]. Another method for assessing the impact of a new therapy is to examine population-based outcomes as the new therapy is introduced to an otherwise stable population. Such a study demonstrated improved outcomes following PCI as coronary stents were introduced into British Columbia in the mid-1990s [5]
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