ABSTRACT: Background. Advances in the safety of percutaneous coronary interventions have been significant in recent years. The goal of this study was to evaluate any decline in the age-adjusted in-hospital mortality rate in patients undergoing multivessel percutaneous coronary intervention (MVPCI) using a very large database from 1988 to 2004 in the United States. Method. The Nationwide Inpatient Sample (NIS) database was utilized to calculate the age-adjusted mortality rate for MVPCI from 1988 to 2004 in patients over the age of 40 years retrospectively. Specific ICD-9-CM codes for MVPCI were used for this study. Patient demographic data were also analyzed and adjusted for age from the database. Results. The mean age was 71.56 ± 10.59 years (53.55% male). From 1988 the age-adjusted mortality rate was stable until 1999, with a steady decline to the lowest level in 2004. In 1988, the rate was 67.42 (95% CI = 181–316.14), in 1999 51.02 (95% CI = 27–129.32), and in 2004, 40.06 (95% CI 5.6–85.83) per 100,000. Total death also declined from 1.77% to 1.25%. This trend was similar across gender and ethnicities. Conclusion. The age-adjusted mortality from MVPCI was steady until 1999, but declined to the lowest level in 2004. This trend most likely reflects advancements in the care of patients undergoing high-risk coronary interventions.
J INVASIVE CARDIOL 2009;21:388–390
Key words: Target lesion revascularization, peripheral intervention, femoropopliteal, clinical outcome
The established treatment options for mechanical revascularization for coronary artery disease (CAD) are coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI).1,2 Older studies showed that CABG is superior to PCI, but it must be noted that in the current era, there have been changes in patient demographics and advancements in medical therapy and technology.3 The advent of drug-eluting stents (DES) has significantly reduced restenosis and target vessel failure (TVF).4,5 Though PCI has been widely used, clinical outcomes after multivessel percutaneous coronary intervention (MVPCI) in the era of stents, glycoprotein (GP) IIb/IIIa inhibitors and clopidogrel pretreatment have not been well studied in large populations and across ethnicities. Therefore, we conducted a study to evaluate whether these advancements in interventional cardiology have affected mortality rates in patients undergoing MVPCI. Using the large Nationwide Inpatient Sample (NIS) database from 1988 to 2004 in the United States, we evaluated in-hospital mortality from MVPCI.
Methods
Data collection and data sources. The Healthcare Cost and Utilization Project (HCUP) includes a set of longitudinal inpatient databases called the NIS, which are created through a federal-state-industry partnership. The NIS helps to identify, track and analyze national trends in health-care utilization such as access, charges, quality and outcomes. It is also the largest all-payer inpatient care database in the United States. Currently, NIS data are available from 1988 to 2004 from 38 states with approximately 8 million hospital stays annually. The NIS database contains discharge information on all patients, regardless of the payer, including persons covered by federal and private insurance, as well as the uninsured with safeguards to protect the privacy of individual patients, physicians and hospitals. In order to exclude most non-atherosclerotic coronary diseases from our study, we used an age cutoff of 40. Furthermore, we calculated age-adjusted mortality based on race and gender.
Description of the data. The NIS database was utilized to calculate the age-adjusted mortality rate for MVPCI from 1988 to 2004 in patients over the age of 40 retrospectively. Specific ICD-9-CM codes for MVPCI (36.05), as discharged, were used for our study. Patient demographic data from the database were also analyzed and adjusted for age.
Statistical analysis. The average age-adjusted in-hospital mortality rates for MVPCI and the 95% confidence intervals (95% CI) for each year were calculated by multiplying the age-specific mortality rates of MVPCI by age-specific weights. The weights used in the age adjustment of the data were the proportion of the year 2000 standard U.S. population within each age group. The weighted rates for each year from 1988 to 2004 were then summed across the age groups for the calculation of the age-adjusted rate. Data analysis was performed using the Statistical Package for the Social Sciences software (SPSS, Inc., Chicago, Illinois).13 Quantitative variables were expressed as means ± standard deviation (SD). For comparison, the independent samples t-test was utilized. A p-value Results
The total sample size from 1988 to 2004 was 41,255,086, and the total number of coded MVPCIs was 237,928, with procedure-related deaths recorded as 3,559. Age-adjusted gender distribution of the study population was as follows: male 67.7 %, female 32.3%. Mortality was equally distributed, occurring in 53.5% of males and in 47.5% of females.
The mean age for these patients was 71.56 ± 10.59 years (53.55% male). From 1988, the age-adjusted mortality rate was stable until 1999, with a steady decline to the lowest level in 2004. In 1988, 67.42 (95% confidence interval [CI] = 181–316.14), in 1999, 51.02 [95% CI = 27–129.32] and in 2004, 40.06 per 100,000 (95% CI 5.6–85.83; Figure 1). Total death from MVPCI procedures also declined from 1.77% to 1.25% (Figure 2). An age-adjusted decline in in-hospital mortality was similar across different ethnicities and gender (Figures 3 and 4).
Discussion
Our study represents a large population of patients that reflects current coronary revascularization practice. The strength of this study is its demonstration of mortality trends for patients undergoing MVPCI over a period of 16 years. Coronary stenting has been employed as a preferred method for mechanical revascularization due to its enhanced procedural safety and reduced rates of restenosis in comparison to balloon angioplasty.6,7 Coronary stenting was not without problems: the frequency of restenosis was > 30% in patients with diabetes mellitus, small coronary vessels and long lesions.8–10 Attempts to reduce restenosis after angioplasty with the use of locally delivered or systemic pharmaceutical agents have been largely unsuccessful until the development of DES.11–14 CABG was traditionally considered as a coronary revascularization procedure for multivessel CAD until a decade ago. The use of DES has reduced restenosis and PCI has been increasingly used for multivessel CAD.15 Multiple studies4,16 have compared the incidence of re-stenosis and have demonstrated that DES offer a reduced incidence of restenosis compared to bare-metal stents. Registry studies17–20 have also reported the success of DES for multivessel disease.
Multivessel PCI was more often associated with periprocedural myocardial infarction than single-vessel intervention, although this did not translate into higher 1-year mortality rates.21 In a comparative study of 148,396 consecutive patients who underwent either PCI or CABG from 1999 through the first quarter of 2002, the unadjusted mortality rate was 1.25% for PCI and 2.63% for CABG (p From the aDivision of Cardiology, The Southern Arizona VA Health Care System, Tucson, Arizona, bDivision of Cardiology, University of Arizona Sarver Heart Center, Tucson, Arizona, and cVA Long Beach Health Care System, Long Beach, California.
The authors report no conflict of interest regarding the content herein.
Manuscript submitted February 13, provisional acceptance given March 30, 2009, final version accepted May 18, 2009.
Address for correspondence: M. Reza Movahed, MD, PhD, FACP, FACC, FSCAI, Associate Professor of Medicine, The Southern Arizona VA Health Care System and University of Arizona Sarver Heart Center, 1501 North Campbell Avenue, Tucson, AZ 85724. E-mail: rmova@aol.com
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