American Heart Association November 18, 2013 Dallas, Texas

Factors influencing treatment decisions for coronary artery disease after cardiac catheterization

American Heart AssociationNovember 18, 2013Dallas, Texas

Brian R. Englum, MD, Phillip Schulte, PhD, Brian Gulack, MD, Manesh R. Patel, MD, John H. Alexander, MD, MHS, Peter K. Smith, MD

All Rights Reserved, Duke Medicine 2008

Disclosure information

• Project funding– Duke University Medical Center

• Conflict of interest to disclose– None

All Rights Reserved, Duke Medicine 2008 Coronary Revascularization Trends in the United States, 2001-2008. JAMA. 2011;305(17):1769-1776.




Previous studies – CAD revasc strategy

• SYNTAX– PCI vs. CABG

• FREEDOM– PCI vs. CABG in diabetics

• COURAGE– PCI vs. Medical therapy in stable CAD

• Observational studies– Differential benefit: diabetes, smoking,

PAD, CHF


Purpose

• Describe trends in treatment strategy for CAD

• Identify factors associated with treatment strategy– Revascularization vs. medical therapy– PCI vs. CABG

• Evaluate changes in these factor with evolving PCI technology


Methods – population• Study population

– Duke Databank for Cardiovascular Disease– CAD: ≥ 1 diseased vessel (50% stenosis) by

coronary angiography– No prior PCI or CABG

• Study eras– Angioplasty: 1986-1995– Bare metal stent: 1996-2003– Drug-eluting stent: 2004-2012


Methods – statistical analysis• Summarized annual rates and patient

characteristics by treatment strategy

• Developed a model of patient characteristics predicting treatment decision– Multivariable logistic regression model– Stepwise variable selection

• Estimated interaction of each variable with era in overall model


Results – revasc strategy over time


Results – patient characteristicsCharacteristic

MED PCI CABG(n=8,672) (n=9,591) (n=8,066)

Age, yrs 63 (54, 71) 59 (51, 68) 64 (56, 71)

Male 65.3% 67.5% 72.7%

Charlson index >0 45.6% 34.2% 41.7%

Cerebrovascular disease 11.9% 6.2% 9.8%

MI 48.9% 60.3% 48.7%

NYHA III/IV 12.3% 3.6% 6.1%

Diabetes –type II 25.3% 21.0% 24.5%

PVD 12.5% 5.8% 11.8%

Smoking 61.4% 58.4% 60.5%

COPD 6.1% 4.5% 3.9%


Results – cardiac disease

Cardiac diseaseMED PCI CABG

(n=8,672) (n=9,591) (n=8,066)

Number of diseased vessels

1 48.4% 57.7% 7.9% 2 27.2% 31.3% 28.2% 3 24.4% 11.1% 63.9%Left main disease 10.5% 3.6% 30.9%EF, % 52 (39, 62) 57 (48, 64) 54 (43, 62)Urgent Catheterization 20.4% 16.1% 21.7%


Results – cardiac factors associated with revasc strategy


Results – comorbidities associated with revasc strategy


Limitations• Single institution data

• Patient preferences

• Provider reasoning

• Anatomic details


Conclusions• Temporal trends in treatment strategies

demonstrate dramatic changes over time

• Decisions in CAD dominated by cardiac factors

• Comorbidities play a lesser role

• Most factors influencing treatment decisions appear stable over time


Factors associated with treatment decisions Revascularization vs. Medical therapy

Characteristic Chi Square Value P-value

Ejection Fraction 243.2 <.0001

Duke CAD Class Severity 131.5 <.0001

CAD Duration 92.0 <.0001

Age 72.9 <.0001

Hx MI 51.4 <.0001

Race 58.6 <.0001

Recent MI (prior 6 weeks) 45.6 <.0001

NYHA Class 67.8 <.0001

Hx Cerebrovascular Disease 29.7 <.0001

Number of Diseased Vessels 37.1 <.0001

Diabetes Status 29.9 <.0001


Factors associated with treatment decision CABG vs. PCI

Characteristic Chi Square Value P-value

Number of Diseased Vessels 571.8 <.0001

Left Main Disease 209.2 <.0001

Duke CAD Class Severity 167.1 <.0001

Recent MI (prior 6 weeks) 42.9 <.0001

Age 34.4 <.0001

Race 31.1 <.0001

Ejection Fraction 30.2 <.0001

BMI 20.7 0.0001

COPD 13.7 0.0033

Connective Tissue Disorder 10.8 0.013

Diabetes Status 13.0 0.043

Documents

American Heart Association November 18, 2013 Dallas, Texas