PCI for Stable CAD Drives Overall Decline in Use of Procedure Since 2009

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National use of percutaneous coronary intervention (PCI) has decreased steadily since 2009, mostly driven by a reduction in procedures for patients with stable coronary artery disease (CAD), according to a large retrospective study published online July 18, 2014, ahead of print in the American Journal of Cardiology

Drop-off in procedural use is likely related to the 2009 appropriate use criteria (AUC) as well as the COURAGE and FAME trials, the paper reports. 

Luke K. Kim, MD, of Weill Cornell Medical College/NewYork-Presbyterian Hospital (New York, NY), and colleagues looked at PCI trends in the United States from the Nationwide Inpatient Sample database between 2007 and 2011.
Overall, 3,305,578 patients underwent PCI during the study period—66.9% for ACS and 33.1% for stable CAD. Patients with stable CAD tended to be older and were more likely to be female and have Medicare coverage, hypertension, diabetes, and peripheral vascular disease. Also, the number of PCI-capable hospitals increased from 347 in 2007 to 387 in 2011. PCI for stable CAD was more common in teaching than nonteaching hospitals.

The annual rate of all PCIs decreased by 27.7% from 10,785 to 7,801 procedures per million adults from 2007-2008 to 2010-2011 (P = .03). The decline represents a 20.3% reduction in the median caseload per hospital given the increase in PCI facilities. 

PCI for ACS stayed steady over the study period, while the number of cases for stable CAD dropped by 51.7% (P = .02). Divided into quartiles, hospitals with higher case volumes had the greatest decreases in use of PCI for stable CAD between 2007 and 2011. 

From 2008 to 2011, PCI use decreased overall in both academic (54.2%; P = .02) and non-academic (48.3%; P = .01) centers, and PCI for ACS decreased by 14.7% and 17.3%, respectively, in both hospital types. 

Geographical analyses showed reductions in PCI use over the study period in all regions, ranging from a decline of 44.5% in the Northeast to 55.4% in the Midwest. PCI utilization also fell across all hospital sizes. 

Furthermore, PCI for stable CAD declined both in patients with Medicare (44.5%; P = .03) and in those with private insurance/HMO (59.5%; P = .007), and a trend toward lower usage was noted for those in both Medicaid and self-pay cohorts. PCI reductions were most notable in white patients (45.7%), who accounted for 88.5% of the total decrease.

Lastly, FFR usage increased by 37.0% (from 64.7 to 102.7 cases per million adults per year) between 2009 and 2011, with a trend toward FFR leading to PCI or conservative therapy. However, IVUS use did not differ over the study period. 

Key Studies Changed Practice

Dr. Kim and colleagues write that the study was designed in such a way as “to assess the impact of the AUC on practice patterns, suggesting a further reduction in PCI volume starting in 2009 in addition to the previously reported decline around the publication of COURAGE data.” 

However, they report that other plausible explanations for declining PCI use could be related to improvements in medical therapy and lifestyle modification, increased DES use leading to less repeat revascularization, and better awareness of late stent thrombosis with DES. Additionally, the authors write, “the potential impact of economic crisis in the [United States] around the study period… may have impacted patient access to healthcare and coronary procedures.”

Increased FFR use, they observe, can be linked with the publication of the FAME trial in January 2009, and this also “may have accentuated the impact of the AUC during the study period.” 

Regarding insurance type, Dr. Kim and colleagues say, the fact that the most substantial PCI declines were seen in the Medicare and private insurance/HMO cohorts is not surprising given that most cases were performed in these patients. “Further analyses will be necessary to better assess the impact of insurance on PCI utilization,” they write.


Kim LK, Feldman DN, Swaminathan RV, et al. Rate of percutaneous coronary intervention for the management of acute coronary syndromes and stable coronary artery disease in the United States (2007-2011). Am J Cardiol. 2014;Epub ahead of print. 

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  • The study was funded by the Michael Wolk Heart Foundation and the New York Cardiac Center.
  • Dr. Kim reports no relevant conflicts of interest.