Steady Decline Seen in PCI Use Over Last Few Years

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The volume of percutaneous coronary interventions (PCIs)—including those for both treatment and diagnostic purposes—decreased steadily from 2004 to 2008, paralleling a decline in overall revascularizations, according to a study of the Medicare population published online February 8, 2011, ahead of print in Circulation: Cardiovascular Quality and Outcomes.

Researchers led by Creighton W. Don, MD, PhD, of the University of Washington (Seattle, WA), analyzed billing data from the Centers for Medicaid and Medicare Services for the period 2001 to 2009 and tracked trends in cardiac catheterizations (diagnostic and interventional), PCI (angioplasty and stents), CABG surgeries, and the use of IVUS and fractional flow reserve (FFR) during angiography.

There was a marked increase in the number of catheterizations from 2001 to 2004, amounting to an average of 5.1% more each year per 1,000 patients. This was followed by a mean decrease of 2.7% per year between 2004 and 2009.

PCI Decrease Followed 2004 Peak

Over the entire 9-year study period, the use of PCI with stenting increased 1.3% from 10.2 to 12.4 per 1,000 beneficiaries. However, the increase primarily occurred from 2001 to 2004 followed by a mean annual decrease of 2.5% from 2004 to 2009. Meanwhile, PCI with balloon angioplasty alone decreased steadily between 2002 and 2005 and remained at roughly 1 per 1,000 beneficiaries for the remainder of the period.

After peaking in 2004, angiography and PCI underwent a notable decrease in 2005 and 2007. In 2009, the number of diagnostic catheterizations and PCI procedures increased slightly compared with 2008 but remained well below the peak 2004 levels. In contrast, CABG procedures declined consistently from a high of 316,951 in 2001 to 199,358 by 2008, followed by a slight increase in 2009. The ratio of PCI to CABG increased steadily from 1.05 per 1,000 beneficiaries in 2001 to 1.72 in 2009, demonstrating that the rate of decline in CABG was greater than PCI over the entire period. Multivessel stenting was relatively constant, comprising about 12% of all PCIs involving stents.

Both IVUS and FFR use increased during the study period. Total IVUS procedures doubled from 0.77 per 1,000 beneficiaries in 2003 (the first year data are available) to 1.53 in 2009, while FFR increased from 0.22 per 1,000 beneficiaries in 2005 (the first year data are available) to 0.41. In addition, the percentage of catheterizations involving FFR increased by 101% from 2005 to 2009.

Multiple Explanations Offered for Decline

The study authors suggest several possible explanations for the decline in rates of coronary catheterization, including increased treatment of atherosclerotic risk factors over the past decade, modifications in risk-factor behaviors including a decrease of 3.5% in the prevalence of smoking among US adults, and more Americans achieving target blood pressure and cholesterol goals.

Another possible explanation may be the increasing use of DES. “The reduction of in-stent restenosis from the use of DES could have led to fewer repeat angiograms and repeat revascularization procedures,” they write. “On the other hand, the concerns for increased stent thrombosis of DES in the latter part of this period also may have contributed to the decrease in PCI seen after 2004.”

In addition, Dr. Don and colleagues say another possibility is that more patients with stable angina are being primarily medically managed or evaluated noninvasively. They point to a recent single-center study that looked at the impact of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluations) trial and found that patients referred for angiography following publication of the study were more often treated with aggressive disease-modifying agents before referral for catheterization than were pre-COURAGE patients. However, since COURAGE was not published until 2007, it does not fully explain the decrease in PCI seen since 2004.

The study authors say their findings echo the decline in CABG rates that began in the late 1980s, although the initial explanation for this, increasing use of PCI, no longer holds true.

“Given the declines in both CABG and PCI since 2004, the use of PCI does not appear to entirely explain the decline in CABG rates,” they write. “Potentially, the decline in CABG surgery volume was simply the canary in the coal mine that signaled larger-scale reductions in the need for coronary revascularization as risk factor modification and cardiovascular therapeutics continue to improve.”

 

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Source:
Riley RF, Don CW, Powell W, et al. Trends in coronary revascularization in the United States from 2001 to 2009: Recent declines in percutaneous coronary intervention volumes. Circ Cardiovasc Qual Outcomes. 2011;Epub ahead of print.

 

 

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