CathPCI Registry Report Details Contemporary US Practice Patterns

New data from a nationwide registry covering nearly 85% of cath labs shed light on contemporary practice patterns in interventional cardiology. The findings, published online October 17, 2012, ahead of print in the Journal of the American College of Cardiology, not only provide a snapshot of the field but also suggest opportunities for quality improvement, researchers say.

Gregory J. Dehmer, MD, of Texas A&M Health Science Center College of Medicine (Temple, TX), and colleagues analyzed data from the CathPCI Registry of the National Cardiovascular Data Registry on 1.1 million patients who underwent diagnostic catheterization alone and 941,248 patients who received PCI at 1,488 facilities in the United States from January 2010 to June 2011.

While feedback has previously been available to participating centers, “there has never really been a public release of this information,” Dr. Dehmer told TCTMD in a telephone interview. Findings from the comprehensive report include:

Hospital Characteristics: Some hospitals (13%) performed more than 1,000 PCIs per year, though half (49%) performed 400 or fewer annually. A quarter (26%) performed 200 or fewer, accounting for about 4% of cases in the registry; 83% of these lowest-volume centers lacked surgical backup.

Patient Characteristics: Two-thirds of PCI patients were men. Though the median age was 65 years, 12.3% were 80 years or older. Comorbidities were prevalent: 80% of those undergoing PCI had dyslipidemia, 82.0% hypertension, and 36.2% diabetes. Most (79.5%) were overweight, with a BMI of at least 25, and 43.4% qualified as obese, with a BMI of at least 30. A substantial minority (27.6%) were current or recent smokers.

Clinical Presentation: Unstable angina was the most common presentation at 36.7%, followed by NSTEMI at 17.9%, stable angina at 17.6%, and STEMI at 15.8%. A full 9.0% of patients were asymptomatic, while 3.0% had symptoms unlikely to be ischemic. Door-to-balloon time averaged 64.5 minutes for STEMI patients who arrived at a PCI center and 121 minutes for STEMI patients who required transfer.

Diagnostic Testing: Nearly half of patients undergoing diagnostic cath (45.5%) had previously had a stress or imaging test, compared to 52.0% of PCI patients who were likely candidates for stress testing. In PCI patients who underwent such testing, the likelihood of abnormal results was 81.8%. Stress myocardial perfusion imaging was performed in 81.9% of PCI patients, while coronary computed tomographic imaging (CTA) was used in only 2.7%. Among the 13% of stenoses treated by PCI that were between 40% and 70% in severity, a quarter went on to additional evaluation using either IVUS (18.5%) or fractional flow reserve (7%).

Procedural Characteristics: Femoral access was used over 90% of the time, with radial access accounting for 8.3% of diagnostic catheterizations and 6.9% of PCIs. At least 1 DES was used in 69.8% of PCI patients, while 21.5% received at least 1 BMS and 8.7% had balloon angioplasty alone. Some type of mechanical support device was used in 2.9% of all PCIs, with intra-aortic balloon pumps chosen 84.4% of the time. Thrombectomy was used in 5.7% of cases and embolic protection devices in 8.0% of saphenous vein graft interventions. More than a third (36.8%) received manual compression. Most patients (86.5%) underwent treatment in 1 vessel only, though the registry did not account for staged procedures. During PCI, 9.9% of patients received low molecular weight heparin, 51.1% unfractionated heparin, 55.9% bivalirudin, and 28.7% glycoprotein IIb/IIIa inhibitors while 76.0% received clopidogrel and 11.2% prasugrel. Ticagrelor was unavailable during the study period.

Complications: Adverse events, including cardiogenic shock, heart failure, pericardial tamponade, cerebrovascular accident/stroke, dialysis, need for CABG, bleeding, and death, were more common in STEMI patients (12.4%) than in those with other indications for PCI (4.53%). For the STEMI subgroup, adjusted in-hospital mortality was 5.2% at hospitals in the 50th percentile for that endpoint and 3.3% at those in the 25^th percentile. The remaining PCI patients saw an unadjusted mortality rate of 0.65%. Bleeding occurred in 3.85% of STEMI patients and 1.40% of other patients.

Room for Improvement

Dr. Dehmer drew attention to the fact that so many facilities performing PCI were low-volume, noting that the 2011 PCI guidelines say the ideal number for a facility is 400 or more per year. “Facilities with 200 or less need to take a careful look at themselves as to whether or not they’re doing adequate volume,” he said. “Maybe they should not continue to do PCI unless they’re in a geographically isolated area.” The statistics are “interesting now that as a nation we’re talking about developing systems of STEMI care,” he added.

Also notable is the fact that CTA use is “very low” despite concerns that the technology would not be used appropriately, Dr. Dehmer observed. “That’s very reassuring, that people are not going hog wild ordering this new expensive test.”

More surprising was the lack of embolic protection. “The data are pretty clear that [the devices are] beneficial [in certain vein grafts],” he stressed, adding, “They’re not perfect, but they work.”

In an e-mail communication with TCTMD, Hitinder S. Gurm, MD, of the University of Michigan Cardiovascular Center (Ann Arbor, MI), commented that given the rise in radial access and FFR, their use also was lower than expected. “I am guessing that if we were to look at data from 2012, we would find an increase [in both],” he said.

The rarity of embolic protection devices does merit attention, as it is “the only metric that is at major odds with the guidelines,” Dr. Gurm noted. “While the guidelines strongly endorse [embolic protection] use, the low use of these devices suggests that physicians are being more circumspect. I think the strong disconnect we see here is worthy of further investigation.”

Are Physicians Paying Attention?

Even so, “I will be surprised if any physician changes his or her practice based on national data. We are more likely to be open to persuasion if we see our own data in comparison to our peers’. Still, it is nice to see what is going on across the country and get a general idea of the landscape,” Dr. Gurm concluded, adding, “We are doing an excellent job overall, and the cardiology community should be proud of the high quality of care that we deliver.”

Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), seemed more wary of the findings. Some simply do not ring true, he told TCTMD in a telephone interview. For example, the in-hospital mortality rate of 0.72% among patients receiving diagnostic cath seems unrealistically high, while he found it unlikely that more than half of PCI procedures involved bivalirudin or heparin, meaning that some patients would have been given more than 1 antithrombin at once.

One explanation, Dr. Brener suggested, is that the self-reported data in the CathPCI Registry can sometimes be unreliable. Only 25 of the participating sites are randomly audited each year, he said, thus raising the possibility of “garbage in, garbage out.”

Despite those limitations, the report is “not altogether bad,” and may spur more discussion on whether low-volume hospitals need surgical backup, Dr. Brener concluded. “It’s very useful . . . so that we have a sense [of current practice].”

---

Source:
Dehmer GJ, Weaver D, Roe MT, et al. A contemporary view of diagnostic cardiac catheterization and percutaneous coronary intervention in the United States: A report from the CathPCI Registry of the National Cardiovascular Data Registry, 2010 through June 2011.

 

 

Related Stories:

• Consensus Document Updates Practice Standards for Cath Labs
• SCAI Launches Nationwide Cath Lab Quality Improvement Effort
• ACC, SCAI Propose Independent Oversight to Ensure Appropriate Stent Use