Utilization Of Percutaneous Coronary Intervention Research Articles

Abstract 13479: Impact of ST-Elevation Myocardial Infarction Among Hospitalized Patients With Coronary Artery Dissection: A United States Population-Based Cohort Study

Introduction: ST-Elevation myocardial infarction (STEMI) is a rare but serious complication of coronary artery dissection (CADi). There is paucity of data on the in-hospital outcomes of hospitalized patients with CADi complicated by STEMI. Methods: We queried the National Inpatient Sample to identify patients with CADi who developed STEMI during the index hospitalization using appropriate ICD-10 codes between 2018-2020. We aim to investigate the impact of STEMI among CADi patients based on in-hospital mortality, risk for cardiogenic shock and arrythmias, utilization of coronary intervention, mechanical circulatory support, and mechanical ventilation. A multivariable logistic regression analysis was used to calculate adjusted odds ratios (ORs) for the outcomes of interest. Results: A total of 20,941 hospitalized patients with CADi were identified, of which 5.42% (1135/20,941) had concomitant STEMI during the index hospitalization. The overall in-hospital mortality rate among hospitalized patients with CADi was 6.45% (1,351/20,930). Among those with concomitant STEMI, the in-hospital mortality was significantly elevated to 18.5% (210/1,135, p= 0.00) compared to those who did not have STEMI. After adjusting for possible confounders, concomitant STEMI in CADi patients was found to be an independent significant predictor of increased risk for cardiogenic shock, development of ventricular tachycardia, ventricular fibrillation, utilization of percutaneous coronary interventions, coronary artery bypass graft, mechanical ventilation, and in-hospital mortality (Table 1). Conclusions: STEMI among CADi patients was independently associated with poorer cardiovascular and in-hospital mortality outcomes. Therefore, prompt recognition and treatment of underlying STEMI in CADi patients is necessary to prevent adverse outcomes.

Abstract 12577: Sex Differences in Outcomes of Percutaneous Coronary Intervention for Stable Coronary Artery Disease in Patients With End Stage Kidney Disease

Introduction: End Stage Kidney Disease (ESKD) patients are at a higher risk of morbidity and mortality from cardiovascular diseases, particularly coronary artery disease (CAD). There is paucity of sex related differences in percutaneous coronary intervention (PCI) outcomes in this population. Methods: Patients ≥ 18 years with ESKD on dialysis for at least 3 months and who underwent PCI for stable CAD between years 2010 and 2018 were identified from the United States Renal Data System (USRDS) database. Appropriate ICD-9/10 codes were used to identify the relevant conditions and procedures. Statistical analyses were performed using the SAS 9.4 software. Results: A total 23,115 ESKD patients underwent PCI, of which 42.5% were women. While there was a declining trend of utilization of PCI (Men: 6.6 to 2.8; Women: 6.6 to 2.7 procedures per thousand ESRD patients; p<0.001), the in-hospital mortality (Men:1% to 3.2%, p<0.001; Women:0.7% to 2.8%, p<0.001), 30-day mortality (Men:3% to 6.8%, p<0.001; Women:3.5% to 5.2%, p<0.001) and 1-year mortality (Men: 25.6% to 32.7%, p<0.001; Women: 27.7% to 30.4%, p<0.001) as well as 30-day myocardial infarction (Men: 2.7% to 4%,p<0.001; Women:3.1% to 5.6%, p<0.001) increased in both sexes during the study period. After propensity matching, hospital length of stay (3 days vs 4 days, p<0.001), 30-day readmission (29.4% vs 33.1%, p<0.001) and 1-year incidence of stroke (2.3% vs 3.3%, p<0.001) were higher in women, while other outcomes were not significantly different between men and women. Conclusions: Despite the decreasing utilization of PCI for stable CAD in ESKD patients over the study period, worsening short- and long-term mortality was observed in both sexes. Women were more likely to have a longer hospital stay as well as readmission within 30 days post-procedure.

Outcomes of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention Among Patients With Acute Coronary Syndrome

Intravascular ultrasound (IVUS) use in percutaneous coronary intervention (PCI) improves outcomes. However, data on outcomes of IVUS-guided PCI in patients presenting with acute coronary syndrome (ACS) is scarce. Therefore, we sought to study the utilization rate and outcomes of IVUS-guided PCI in patients with ACS. Using the National Readmission database, we identified all patients with ACS who underwent PCI from 2016 to 2019. We used a 1:1 propensity-matched analysis to compare the outcome of patients with ACS who underwent PCI with and without IVUS. In 1,263,997 patients with ACS, 563,521 (44.6%) underwent PCI without IVUS and 40,095 (3.17%) underwent IVUS-guided PCI. A Propensity scored matched comparison of PCI with and without IVUS showed IVUS-guided PCI was associated with a lower risk of in-hospital mortality (odds ratio 0.74, 95% confidence interval 0.64 to 0.85, p <0.01) compared with PCI without IVUS. The utilization of IVUS increased from 2.64% in 2016 to 4.10% in 2019, p <0.001. In conclusion, IVUS-guided PCI is associated with lower in-hospital mortality in patients with ACS, yet the current utilization of IVUS-guided PCI remains low across the United States.

Ad Hoc Percutaneous Coronary Intervention in Stable Patients With Multivessel or Unprotected Left Main Disease

BackgroundThere is very little information about the use of ad hoc percutaneous coronary intervention (PCI) in stable patients with multivessel (MV) disease or unprotected left main (LM) disease patients for whom a heart team approach is recommended. ObjectiveTo identify the extent of ad hoc PCI utilization for patients with multivessel disease or left main disease, and to explore the inter-hospital variation in ad hoc PCI utilization for those patients. MethodsNew York State’s cardiac registries were used to examine the use and variation in use of ad hoc PCI for MV/LM disease as a percentage of all MV/LM PCIs and revascularizations (PCIs plus coronary artery bypass graft procedures) during 2018 to 2019 in New York. ResultsAfter exclusions, 6,425 of the 8,196 stable PCI patients with MV/LM disease (78.4%) underwent ad hoc PCI, ranging from 58.7% for patients with unprotected LM disease to 85.4% for patients with 2-vessel proximal left anterior descending (PLAD) disease. Ad hoc PCIs comprised 35.1% of all revascularizations, ranging from 11.5% for patients with unprotected LM disease to 63.9% for patients with 2-vessel PLAD disease. The risk-adjusted utilization of ad hoc PCI as a percentage of all revascularizations varied widely among hospitals (eg, from 15% in the first quartile to 46% in the last quartile for 3-vessel disease). ConclusionsAd hoc PCIs occur frequently even among patients with MV/LM disease. This is particularly true among patients with 2-vessel PLAD disease. The frequency of ad hoc PCIs is lower but still high among patients with diabetes and low ejection fraction and higher in hospitals without surgery on-site (SOS). Given the magnitude of hospital- and physician-level variation in the use of ad hoc PCIs for such patients, consideration should be given to a systems approach to achieving heart team consultation and shared decision making that is consistent for SOS and non-SOS hospitals.

Acute Myocardial Infarction-Related Hospitalizations in Non-elderly Patients with Pneumonia: a Population-Based Study.

The objective is to study factors that increase the likelihood of acute myocardial infarction (AMI) in hospitalized adult non-elderly patients with pneumonia compared to other medical inpatients and to understand the utilization rate of percutaneous coronary intervention (PCI) for AMI in inpatients with pneumonia and its related impact on hospitalization stay and cost. A population-based study was conducted using the Nationwide Inpatient Sample (NIS, 2019) with adult non-elderly inpatients (age 18-65years) with a medical condition as their primary diagnosis and a co-diagnosis of pneumonia during hospitalization stay. This study sample was divided by the primary diagnosis of AMI versus other medical conditions (non-AMI). A logistic regression model was used to evaluate the odds ratio (OR) of predictors associated with AMI in patients with pneumonia. The results showed a direct relationship between increasing age and the likelihood of AMI in pneumonia inpatients with three times higher odds seen in 51-65years of age (OR 2.95, 95% CI 2.82-3.09). The comorbidities included complicated hypertension (OR 2.84, 95% CI 2.78-2.89), diabetes with complications (OR 1.27, 95% CI 1.24-1.29), and drug abuse (OR 1.27, 95% CI 1.22-1.31) that increased the likelihood of AMI-related hospitalization. The utilization rate of surgical treatment (PCI) was 14.37% for the management of AMI in inpatients with pneumonia. Inpatients co-diagnosed with pneumonia and comorbidities such as hypertension and diabetes were more likely to be hospitalized for AMI. These at-risk patients should be considered for early risk stratification. Utilization of PCI was associated with a lower in-hospital mortality rate.

Assessing the condition of percutaneous coronary intervention services in Africa: challenges and prospects for advancement - a review.

This study assesses the state of percutaneous coronary intervention (PCI) services in Africa, identifying the challenges and prospects for improvement. The study highlights limited infrastructure, resources, and the healthcare workforce as significant challenges in providing adequate PCI services to the population. However, opportunities for improvement are available through increased investment in healthcare infrastructure, healthcare professional training programs, and telemedicine. Collaboration among governments, healthcare providers, and international organizations is essential to address these challenges and improve access to high-quality PCI services for all Africans. Improving PCI facilities and utilization will not only benefit current and future patients with cardiovascular disease but will also advance healthcare as a whole in Africa.

A-23 | Gender Disparities in Cardiovascular Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusions

Several studies have demonstrated the utility of percutaneous coronary intervention (PCI) in improving cardiovascular outcomes in patients with chronic total occlusions (CTOs). However, the differences in clinical outcomes based on gender have not been well elucidated. This meta-analysis aims to evaluate the differences in cardiovascular outcomes of CTO PCI based on gender. A literature search was conducted for studies reporting on clinical endpoints after CTO PCI based on gender. The primary endpoint was all-cause mortality. Secondary endpoints included procedural success, recurrent acute myocardial infarction (AMI), and composite major adverse cardiovascular events (MACE). The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. A total of 14 studies with 15,129 patients with CTO PCIs (2804 females, 12325 males) met inclusion criteria. Mean follow-up was 48 months. Female gender was associated with a trend toward higher risk of all-cause mortality and MACE and lower procedural success; however, this was not statistically significant (OR 1.2, 95% CI 0.98-1.48; p=0.08; OR 1.26, 95% CI 0.99-1.59; p=0.06; OR 1.12, 95% CI 0.98-1.27; p=0.08). There was no significant difference in the risk of recurrent AMI on long-term follow-up post-PCI in females compared to males (OR 1.07, 95% CI 0.82-1.40; p=0.61). Female patients who undergo CTO PCI have similar procedural success without increased risk of long-term all-cause mortality, MACE, or recurrent AMI compared to male patients.

Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review.

Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.

Impact of COVID-19 on percutaneous coronary intervention utilization and mortality in New York.

COVID-19 has disrupted the care of all patients, and little is known about its impact on the utilization and short-term mortality of percutaneous coronary intervention (PCI) patients, particularly nonemergency patients. New York State's PCI registry was used to study the utilization of PCI and the presence of COVID-19 in four patient subgroups ranging in severity from ST-elevation myocardial infarction (STEMI) to elective patients before (December 01, 2018-February 29, 2020) and during the COVID-19 era (March 01, 2020-May 31, 2021), as well as to examine the impact of different COVID severity levels on the mortality of different types of PCI patients. Decreases in the mean quarterly PCI volume from the prepandemic period to the first quarter of the pandemic ranged from 20% for STEMI patients to 61% for elective patients, with the other two subgroups having decreases in between these values. PCI quarterly volume rebounds from the prepandemic period to the second quarter of 2021 were in excess of 90% for all patient subgroups, and 99.7% for elective patients. Existing COVID-19 was rare among PCI patients, ranging from 1.74% for STEMI patients to 3.66% for elective patients. PCI patients with COVID-19 and acute respiratory distress syndrome (ARDS) who were not intubated, and PCI patients with COVID-19 and ARDS who were either intubated or were not intubated because of Do Not Resuscitate//Do Not Intubate status had higher risk-adjusted mortality ([adjusted ORs = 10.81 [4.39, 26.63] and 24.53 [12.06, 49.88], respectively]) than patients who never had COVID-19. There were large decreases in the utilization of PCI during COVID-19, with the percentage of decrease being highly sensitive to patient acuity. By the second quarter of 2021, prepandemic volumes were nearly restored for all patient subgroups. Very few PCI patients had current COVID-19 throughout the pandemic period, but the number of PCI patients with a COVID-19 history increased steadily during the pandemic. PCI patients with COVID-19 accompanied by ARDS were at much higher risk of short-term mortality than patients who never had COVID-19. COVID-19 without ARDS and history of COVID-19 were not associated with higher mortality for PCI patients as of the second quarter of 2021.

Impact of frailty on outcomes in acute ST-elevated myocardial infarctions undergoing percutaneous coronary intervention.

We analyzed the impact of frailty on readmission rates for ST-elevated myocardial infarctions(STEMIs) and the utilization of percutaneous coronary intervention(PCI) in STEMI admissions. The 2016-2019 Nationwide Readmission Database was analyzed for patients admitted with an acute STEMI. Patients were categorized by frailty risk and analyzed for 30-day readmission risk after acute STEMIs, PCI utilizationand outcomes, and healthcare resource utilization. Qualifying index admissions were found in 584,918 visits. Low risk frailty was noted in 78.20%, intermediate risk in 20.67%, and high risk in 1.14% of admissions. Thirty-day readmissions occurred in 7.74% of index admissions, increasing with frailty (p < 0.001). Readmission risk increased with frailty, 1.37 times with intermediate and 1.21 times with high-risk frailty. PCI was performed in 86.40% of low-risk, 66.03% of intermediate-risk, and 58.90% of high-risk patients (p < 0.001). Intermediate patients were 55.02% less likely and high-risk patients were 61.26% less likely to undergo PCI (p < 0.001). Length of stay means for index admissions were 2.96, 7.83, and 16.32 days for low, intermediate, and high-risk groups. Intermediate and high-risk frailty had longer length of stay, higher total cost, and were more likely to be discharged to a skilled facility (p < 0.001). Among adult, all-payer inpatient visits, frailty discerned by the hospital frailty risk scorewas associated with increased readmissions, increased healthcare resource utilization, and lower PCIadministration.

Coronary Angiography in Patients With Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation on Electrocardiograms: A Comprehensive Review

<h2>Abstract</h2> Out-of-hospital cardiac arrest (OHCA) is among the most common causes of death in the United States. Early coronary angiography (CAG) and percutaneous coronary intervention (PCI) have been associated with improved long-term outcomes in patients with ST-segment elevation (STE) on prearrest or postarrest electrocardiograms. However, data on the utility of catheterization and PCI for improving outcomes after OHCA in patients without STE on electrocardiograms are heterogeneous, with variable results. Although older data have suggested that there is a benefit, recent randomized controlled trials have demonstrated that performing early CAG in patients with OHCA without STE on electrocardiograms may not improve outcomes. In recognition that neurologic devastation and multiorgan failure are common in these patients, physicians face the challenge of selecting appropriate patients for cardiac catheterization and PCI. This review aims to summarize the current data on this topic, with the goal to guide decision making regarding the timing and appropriateness of CAG in patients with OHCA without STE on electrocardiograms, utilizing an evidence-based approach to streamline the patient selection process.

Incidence and outcomes of cardiogenic shock among women with spontaneous coronary artery dissection.

There is a paucity of data on cardiogenic shock (CS) incidence and outcomes among patients with spontaneous coronary artery dissection (SCAD). Women admitted to the hospital for acute myocardial infarction (AMI) with and without SCAD were identified from the United States National Readmission Database from October 1, 2015 to December 31, 2018. We calculated the incidence of CS among women with AMI with and without SCAD and odds for developing CS after adjusting for baseline characteristics. In addition, we report the utilization of percutaneous coronary intervention, mechanical circulatory support, severe disability surrogates, and 30-day readmission rates. A total of 664,292 patients admitted for AMI were eligible for analysis, including 6643 patients with SCAD and 657,649 without SCAD. Patients with SCAD were younger (57 years [interquartile range,IQR 48-68] vs. 71 years [IQR 60-81], p < 0.01) and had fewer comorbidities yet had a higher incidence of CS as compared to patients without SCAD (9% vs. 5%, p < 0.01) and remained at elevated risk after adjusting for baseline comorbidities (adjusted odds ratio 1.5 [95% confidence interval,CI 1.2-1.7]). Among patients who developed CS, those with SCAD had lower in-hospital mortality than non-SCAD (31% vs. 39%, p < 0.01), and were more likely to receive mechanical circulatory support. In a nationally representative sample of women admitted for AMI, we found that patients with SCAD had a higher risk of developing CS and required more frequent use of mechanical circulatory support but were more likely to survive to discharge than women suffering AMI from causes other than SCAD.

Fractional Flow Reserve Cardio-Oncology Effects on Inpatient Mortality, Length of Stay, and Cost Based on Malignancy Type: Machine Learning Supported Nationally Representative Case-Control Study of 30 Million Hospitalizations.

Background and Objectives: There are no nationally representative studies of mortality and cost effectiveness for fractional flow reserve (FFR) guided percutaneous coronary interventions (PCI) in patients with cancer. Our study aims to show how this patient population may benefit from FFR-guided PCI. Materials and Methods: Propensity score matched analysis and backward propagation neural network machine learning supported multivariable regression was performed for inpatient mortality in this case-control study of the 2016 National Inpatient Sample (NIS). Regression results were adjusted for age, race, income, geographic region, metastases, mortality risk, and the likelihood of undergoing FFR versus non-FFR PCI. All analyses were adjusted for the complex survey design to produce nationally representative estimates. Results: Of the 30,195,722 hospitalized patients meeting criteria, 3.37% of the PCIs performed included FFR. In propensity score adjusted multivariable regression, FFR versus non-FFR PCI significantly reduced inpatient mortality (OR 0.47, 95%CI 0.35–0.63; p < 0.001) and length of stay (LOS) (in days; beta −0.23, 95%CI −0.37–−0.09; p = 0.001) while increasing cost (in USD; beta $5708.63, 95%CI, 3042.70–8374.57; p < 0.001), without significantly increasing complications overall. FFR versus non-FFR PCI did not specifically change cancer patients’ inpatient mortality, LOS, or cost. However, FFR versus non-FFR PCI significantly increased inpatient mortality for Hodgkin’s lymphoma (OR 52.48, 95%CI 7.16–384.53; p < 0.001) and rectal cancer (OR 24.38, 95%CI 2.24–265.73; p = 0.009). Conclusions: FFR-guided PCI may be safely utilized in patients with cancer as it does not significantly increase inpatient mortality, complications, and LOS. These findings support the need for an increased utilization of FFR-guided PCI and further studies to evaluate its long-term impact.

Drug Eluting Stents versus Coronary Artery Bypass Graft Surgery for Patients with Diabetes Mellitus and Multivessel Disease

&#x0D; Background: through coronary artery bypass graft (CABG) or through utilization of percutaneous coronary intervention (PCI) with stenting, coronary revascularization can be achieved. Diabetics represents a particularly challenging group for both treatments. This work aimed to estimate clinical outcome in diabetic individuals with multiple vessels disease (MVD) who had either PCI or CABG over 30 days.&#x0D; Methods: This prospective research was conducted on 200 diabetic individuals with MVD established as severe stenosis. Into 2 equal groups, individuals were divided: Group (A) [underwent CABG], and group (B) [performed Drug Eluting Stents (DES) PCI]. All individuals underwent full history taking, resting twelve-leads electrocardiogram, complete clinical examination, transthoracic echocardiography, coronary angiographic, SYNTAX score and Euro score.&#x0D; Results: In CABG group, age, statin, ACE-I/ARB, β- -blocker and dual antiplatelet therapy was significantly higher than PCI group. PCI group had significantly higher PCI, MI and repeated revascularization than the group of CABG. In PCI group, stroke and MI, death, myocardial infarction (MI), were significantly higher than in group of CABGS.&#x0D; Conclusions: DES have developed for the coronary artery disease (CAD) treatment and are increasingly being utilized for complex CAD treatment, such as multivessel or left main CAD. PCI is preferred over CABG in high surgical risk individuals due to the shorter hospital stay, faster time of recovery, and potentially decreased stroke rate.&#x0D; &#x0D;

Redo Coronary Artery Bypass Grafting in the era of Advanced PCI.

Objective To review the evidence behind the role and relevance of redo coronary artery bypass grafting (CABG) in the current practice of percutaneous coronary intervention (PCI).Methods A comprehensive electronic literature search was performed to identify articles that discuss the practice of PCI and redo CABG in patients that require coronary revascularization. All relevant studies are summarized in narrative manner to reflect current indications and preference.Results The advancement in utilization of PCI has reduced the rate of redo CABG in patients with previous CABG that requires revascularization of an already treated coronary disease or a new onset of coronary artery stenosis. Redo CABG is associated with satisfactory perioperative outcomes but higher mortality at immediate postoperative period when compared to PCI.Conclusion Redo CABG patients are less likely to develop comorbidities associated with revascularisation, but the operative mortality is higher and long-term survival rates are similar in comparison to PCI. There is a need for further research into the role of redo CABG in the current advanced practice of PCI.

Multi-Center, Prospective, Nation-Wide Coronary Angioplasty Registry in Thailand (Thai PCI Registry): Registry Design and Rationale

Background: Coronary artery disease (CAD) is one of the most common causes of death worldwide. Percutaneous coronary intervention (PCI) is currently the main revascularization modality for these patients. The practice of PCI, outcomes and resource utilization varies in many parts of the world. Therefore, it is important to have local information regarding the patient demographics, pattern of PCI practice, and outcomes. Objective: To report the study design, protocol and rationale of the Thai PCI registry. Materials and Methods: Thai PCI Registry is a prospective, multi-center study which is an initiative project of the Cardiac Intervention Association of Thailand (CIAT). The study consisted of phase I for cross-sectional data registry and phase II for follow up study. The project was started in November 2015. All catheterization laboratories in Thailand were invited to participate in this nationwide registry. The details regarding patient characteristics, procedural details, equipment, and outcomes of PCI were prospectively collected using well-constructed case record form. The protocol of the registry has been approved by the Central Research Ethics Committee (CREC). The project received a research grant from the Health System Research Institute, The Ministry of Public Health, in Thailand, March 2017. Results: There were 39 hospitals from all areas of the country participated in the registration. The hospital type and size were varied and well represented of the PCI centers in Thailand. The registry planned to enroll all consecutive PCI patients at each hospital for approximately one year with the estimated number of PCI at 22,000 procedures. Initially, all patients were followed up for at least 6 and 12 months. Conclusion: The present study provides rationale, protocol, definition and study design of Thai PCI registry. The results of the Thai PCI registry would yield the essential information regarding the current real-world practice as well as the results and complications of PCI. Keywords: Coronary angioplasty; Nationwide registry; Percutaneous coronary intervention; Thailand; Real-world

Rates of revascularization and PCI:CABG ratio: a new indicator predicting in-hospital mortality in acute coronary syndromes.

The principal trend in acute coronary syndrome (ACS) is increasing utilization of percutaneous coronary interventions (PCI) and declining coronary artery bypass graft surgery (CABG) utilization. This study was designed to evaluate whether higher PCI:CABG ratios lead to higher in-hospital PCI or CABG mortality. The National Readmission Database for years 2016 was queried for all hospitalized ACS patients who underwent coronary revascularization during their admission. The study population was derived from 355 US hospitals and included 103 021 patients. Hospitals were grouped based on their PCI:CABG ratio into low, intermediate, and high ratio quartiles with a median [interquartile ranges (IQR)] PCI:CABG ratio of 2.9 (2.5-3.2), 5.0 (4.3-5.9) and 8.9 (7.8-10.3), respectively multivariable logistic regression with adjustment for age, demographics and comorbidities were used to identify CABG:PCI ratio related risk for in-hospital CABG and PCI mortality. Higher PCI:CABG ratios correlated with an increased CABG mortality. There was a median (IQR) mortality of 2.5% (1.6-4.3) in the low ratio quartile; 3.1% (1.9-5.3) in the intermediate quartiles; and 5.3% (3.2-9.1) in the high ratio quartile (P < 0.001). On multivariate analysis, the PCI:CABG ratio was associated with an increased risk for CABG mortality with an adjusted odds ratio of 1.38 (95% CI, 1.14-1.67, P < 0.001) and 2.17 (95% CI, 1.70-2.80, P < 0.001) for hospitals with intermediate and high PCI:CABG ratios, respectively. There was no significant association between PCI:CABG ratio and PCI mortality. The programmatic PCI:CABG ratio is a valid indicator of optimal case selection. The PCI:CABG ratio correlates with in-hospital mortality in ACS.

Zero contrast optical coherence tomography-guided percutaneous coronary intervention in patients with non-ST segment elevation myocardial infarction and chronic kidney disease.

To investigate a strategy for ultra-low volume contrast percutaneous coronary intervention (PCI) with the aims of preserving renal function and observing the 90-day clinical endpoint in patients with non-ST-elevated myocardial infarction (non-STEMI) and chronic kidney disease (CKD). The feasibility, safety, and clinical utility of PCI with ultra-low radio-contrast medium in patients with non-STEMI and CKD are unknown. A total of 29 patients with non-STEMI and CKD (estimated glomerular filtration rate [eGFR] of ≤60 ml/min/1.73 m2 ) were included. Ultra-low volume contrast PCI was performed after minimal contrast coronary angiography using zero contrast optical coherence tomography (OCT) guidance. Pre- and post-PCI angiographic measurements were performed using quantitative flow ratio (QFR) for pre-perfusion assessment and verifying improvement. The median creatinine level was 2.1 (inter-quartile range 1.8-3.3), and mean eGFR was 48 ± 8 ml/min/1.73 m2 pre-PCI. During the PCI procedure, OCT revealed 15 (52%) cases of abnormalities post-dilation. There was no significant change in the creatinine level and eGFR in the short- or long-term, and no major adverse events were observed. In non-STEMI patients with high-risk CKD who require revascularization, QFR and no contrast OCT-guided ultra-low contrast PCI may be performed safely without major adverse events.

Revascularisation strategies in patients with significant left main coronary disease during the COVID-19 pandemic.

BackgroundThere are limited data on the impact of the COVID‐19 pandemic on left main (LM) coronary revascularisation activity, choice of revascularisation strategy, and post‐procedural outcomes.MethodsAll patients with LM disease (≥50% stenosis) undergoing coronary revascularisation in England between January 1, 2017 and August 19, 2020 were included (n = 22,235), stratified by time‐period (pre‐COVID: 01/01/2017–29/2/2020; COVID: 1/3/2020–19/8/2020) and revascularisation strategy (percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG). Logistic regression models were performed to examine odds ratio (OR) of 1) receipt of CABG (vs. PCI) and 2) in‐hospital and 30‐day postprocedural mortality, in the COVID‐19 period (vs. pre‐COVID).ResultsThere was a decline of 1,354 LM revascularisation procedures between March 1, 2020 and July 31, 2020 compared with previous years' (2017–2019) averages (−48.8%). An increased utilization of PCI over CABG was observed in the COVID period (receipt of CABG vs. PCI: OR 0.46 [0.39, 0.53] compared with 2017), consistent across all age groups. No difference in adjusted in‐hospital or 30‐day mortality was observed between pre‐COVID and COVID periods for both PCI (odds ratio (OR): 0.72 [0.51. 1.02] and 0.83 [0.62, 1.11], respectively) and CABG (OR 0.98 [0.45, 2.14] and 1.51 [0.77, 2.98], respectively) groups.ConclusionLM revascularisation activity has significantly declined during the COVID period, with a shift towards PCI as the preferred strategy. Postprocedural mortality within each revascularisation group was similar in the pre‐COVID and COVID periods, reflecting maintenance in quality of outcomes during the pandemic. Future measures are required to safely restore LM revascularisation activity to pre‐COVID levels.

Trends in the utilization and reimbursement of coronary revascularization in the United States Medicare population from 2010 to 2018.

To determine utilization and reimbursement trends of coronary revascularization procedures in the US Medicare population from 2000 to 2018. US Medicare population is increasing, and coronary revascularization decreased in the 2000s. This is a population-based, cross sectional study of US Medicare beneficiaries from 2010 to 2018. The Centers for Medicare and Medicaid Services' database was queried for revascularization procedures using the coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) current procedural terminology (CPT) codes. Trends in Medicare enrollees, PCIs, CABGs, and physician reimbursements were analyzed. Total utilization and reimbursement decreased for both revascularization procedures. The national CABG and PCI utilization per enrollee has decreased by 40.7% (best fit line: b coefficient, 95% CI; -0.297, -0.358 to -0.235) and 26.4% (best fit line: -0.229, -0.373 to -0.0858), respectively. For CABG, annual Medicare payout per enrollee and physician compensation per procedure has decreased by 49.3% (best fit line: -0.250, -0.315 to -0.185) and 14.5% (best fit line: -11.54, -15.62 to -7.452), respectively, and for PCI, decreased by 53.3% (best fit line: -0.373, -0.560 to -0.186) and 36.6% (best fit line: -34.15, -49.35 to -18.95), respectively. Amongst the states, there was significant variability in procedure utilization, and CABG reimbursement rates but minimal variability in PCI reimbursement rates. Even though the US population has aged, revascularization utilization and reimbursement continue to decline. Advancement in medical intervention strategies, particularly non-surgical management, may account for these trends. Further understanding of these trends will allow health systems to tailor resources to the aging population.