Substantial Decline Seen in CABG Over Last Decade, But PCI Rates Unchanged

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A cross-sectional study of US patients undergoing coronary revascularization suggests a fairly dramatic shift in approach to treatment with a 38% decrease in the number of coronary artery bypass graft (CABG) surgeries since 2001. Meanwhile, the rate of percutaneous coronary intervention (PCI) has remained relatively stable, researchers report in the May 4, 2011, issue of the Journal of the American Medical Association.

Researchers led by Peter W. Groeneveld, MD, MS, of the University of Pennsylvania School of Medicine (Philadelphia, PA), used a representative national sample of hospitalization claims to estimate trends in the annual volume of coronary revascularization procedures. Data on patients undergoing CABG or PCI between 2001 and 2008 at US hospitals in the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample were supplemented by Medicare outpatient hospital claims.

Overall, there was a 15% decrease in the annual rate of coronary revascularization from the early years of the study (2001-2002) to the end of the study (2007-2008). CABG accounted for most of this decrease, with approximately 38% fewer surgeries being performed in 2008 compared with 2001. The annual CABG rate decreased steadily over this time period, while the PCI rate—including the use of DES, BMS, and angioplasty without stenting—remained relatively unchanged, showing a decrease of about 4% over the same interval (table 1).

Table 1. Annual Rates of Coronary Revascularization per Million Adults

 

2001-2002

2007-2008

P Value

CABG

1,742 (31%)

1,081 (23%)

< 0.001

PCI

3,827 (69%)

3,667 (77%)

0.74


Projected to the entire US population, the changes suggest that 130,000 fewer CABG surgeries were performed in 2008 compared with 2001.

Also notable was the finding that the number of hospitals providing CABG increased by 12% over the study period. When this increase was combined with the decrease in annual CABG surgeries, the result was a 28% decrease in the median caseload per hospital and a substantial increase in the number of hospitals providing fewer than 100 CABG surgeries per year (from 11% in 2001 to 26% in 2008, P < 0.001). According to Dr. Groeneveld and colleagues, these findings “highlight the increasing role of low-volume hospitals in the provision of CABG surgery.”

The authors also tracked changes in the use of DES beginning with their approval by the US Food and Drug Administration in April 2003. By the third quarter of 2005, DES as a percentage of all PCI procedures peaked at nearly 90% and later decreased to 61% during 2006 to 2007 following an explosion of concern and debate over the risk of late stent thrombosis. However, data from the final calendar quarter of 2008 indicated DES use had rebounded slightly, increasing to 68% of all PCI procedures.

Not Terribly Surprising, But Concerns Raised

“The data on total revascularization are not terribly surprising in that the rate of cardiovascular disease in the United States also is going down and has been for a while now,” Dr. Groeneveld said in a telephone interview with TCTMD. “But clearly what we see is that there has been a substantial decline in CABG over that period, a decline of almost 40%. That’s remarkable because CABG is one of the most common surgeries done in US hospitals and remains a perfectly acceptable treatment choice . . . and for some patients it remains the preferable choice. If we saw equivalent rates of decline in both CABG and PCI, I think we would just shrug and not be too concerned.”

Dr. Groeneveld said the primary concern is that some patients who might be most appropriately treated with CABG are instead being treated with PCI. He added that the data reflect a “sea change in how coronary revascularization is done in the United States, with it being significantly more likely now that a patient will get PCI rather than CABG compared with 10 years ago.”

But the reasons for the change are likely multifactorial, and the study was not powered to distinguish which patients were more appropriate candidates for CABG vs. PCI, nor were data available on anatomy or other characteristics that may have been deciding factors in their treatment. Additionally, patient preference and the increasing popularity of minimally invasive procedures likely are significant components. However, Dr. Groeneveld pointed out that advances in CABG over the last 10 years have made the surgery easier, despite its apparent waning popularity with patients and their physicians.

Dr. Groeneveld said he believes greater scrutiny is needed as well as more collaboration between specialties, particularly in cases of triple vessel disease and left main disease, to ensure that the best treatment is offered to the patient.

“I’m not trying to take away anyone’s choice or advocate some kind of prohibition against PCI in these cases,” he said. “At the same time, a patient is often already in the cath lab, having just been diagnosed with triple vessel disease, when a decision is made to go ahead with PCI. That’s a concern because it’s not the optimal decision-making time for the patient, although in some cases it’s understandable. But if we do that a lot, we are not serving our patients as well as we could. What needs to happen is more conversations in advance of cardiac catheterization.”

Ad Hoc PCI Deserves Thorough Discussion

In an e-mail communication with TCTMD, Gregg W. Stone, MD, of Columbia University Medical Center (New York, NY), agreed with Dr. Groeneveld that ad hoc PCI should not be performed in patients with more complex CAD, including triple vessel and left main disease.

“For such patients a thorough discussion should be had between the interventionalist, surgeon, general cardiologist, and patient to determine the best course of care,” he concurred.

But Dr. Stone added that in the SYNTAX trial, which compared PCI using DES to CABG in patients with left main and triple vessel disease, overall quality of life in the first year after treatment was superior with PCI, “which is why patients prefer less invasive therapies.”

Additionally, he said DES have markedly reduced restenosis, extending the durability of PCI.

Dr. Stone pointed to a recent study (Ryan J, et al.Circulation.2009;119:952-961) showing that the increased use of DES and an associated decrease in CABG rates have resulted in reduced costs per revascularized patient, with concomitantly reduced rates of repeat revascularization and MI with similar risk-adjusted mortality. The SYNTAX trial, meanwhile, found similar rates of hard endpoints (death, MI, and stroke) between DES and CABG, “except possibly in those patients with the most complex coronary anatomy who should preferentially be treated with CABG,” he added.

 


Source:
Epstein AJ, Polsky D, Yang F, et al. Coronary revascularization trends in the United States, 2001-2008. JAMA. 2011;305:1769-1776.

 

 

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Disclosures
  • The study was supported by grants from the National Heart, Lung, and Blood Institute and from the Agency for Healthcare Research and Quality. It also was funded in part under a grant from the Pennsylvania Department of Health.
  • Dr. Groeneveld reports no relevant conflicts of interest.
  • Dr. Stone reports serving on the scientific advisory boards for and receiving honoraria from Abbott Vascular and Boston Scientific and serving as a consultant for AstraZeneca, Bristol-Myers Squibb/Sanofi, Eli Lilly, Medtronic, and Merck.

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