Factors influencing treatment decisions for coronary artery disease after cardiac catheterization American Heart Association November 18, 2013 Dallas,

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Presentation transcript:

Factors influencing treatment decisions for coronary artery disease after cardiac catheterization American Heart Association November 18, 2013 Dallas, Texas Brian R. Englum, MD, Phillip Schulte, PhD, Brian Gulack, MD, Manesh R. Patel, MD, John H. Alexander, MD, MHS, Peter K. Smith, MD

All Rights Reserved, Duke Medicine 2008 Disclosure information Project funding –Duke University Medical Center Conflict of interest to disclose –None

All Rights Reserved, Duke Medicine 2008 Coronary Revascularization Trends in the United States, JAMA. 2011;305(17):

All Rights Reserved, Duke Medicine 2008 Coronary Revascularization Trends in the United States, JAMA. 2011;305(17):

All Rights Reserved, Duke Medicine 2008 Coronary Revascularization Trends in the United States, JAMA. 2011;305(17):

All Rights Reserved, Duke Medicine 2008 Previous studies – CAD revasc strategy SYNTAX –PCI vs. CABG FREEDOM –PCI vs. CABG in diabetics COURAGE –PCI vs. Medical therapy in stable CAD Observational studies –Differential benefit: diabetes, smoking, PAD, CHF

All Rights Reserved, Duke Medicine 2008 Purpose Describe trends in treatment strategy for CAD Identify factors associated with treatment strategy –Revascularization vs. medical therapy –PCI vs. CABG Evaluate changes in these factor with evolving PCI technology

All Rights Reserved, Duke Medicine 2008 Methods – population Study population –Duke Databank for Cardiovascular Disease –CAD: ≥ 1 diseased vessel (50% stenosis) by coronary angiography –No prior PCI or CABG Study eras –Angioplasty: –Bare metal stent: –Drug-eluting stent:

All Rights Reserved, Duke Medicine 2008 Methods – statistical analysis Summarized annual rates and patient characteristics by treatment strategy Developed a model of patient characteristics predicting treatment decision –Multivariable logistic regression model –Stepwise variable selection Estimated interaction of each variable with era in overall model

All Rights Reserved, Duke Medicine 2008 Results – revasc strategy over time

All Rights Reserved, Duke Medicine 2008 Results – patient characteristics Characteristic MEDPCICABG (n=8,672)(n=9,591)(n=8,066) Age, yrs63 (54, 71)59 (51, 68)64 (56, 71) Male65.3%67.5%72.7% Charlson index >045.6%34.2%41.7% Cerebrovascular disease11.9%6.2%9.8% MI48.9%60.3%48.7% NYHA III/IV 12.3%3.6%6.1% Diabetes –type II25.3%21.0%24.5% PVD12.5%5.8%11.8% Smoking61.4%58.4%60.5% COPD6.1%4.5%3.9%

All Rights Reserved, Duke Medicine 2008 Results – cardiac disease Cardiac disease MEDPCICABG (n=8,672)(n=9,591)(n=8,066) Number of diseased vessels 148.4%57.7%7.9% 227.2%31.3%28.2% 324.4%11.1%63.9% Left main disease10.5%3.6%30.9% EF, %52 (39, 62)57 (48, 64)54 (43, 62) Urgent Catheterization20.4%16.1%21.7%

All Rights Reserved, Duke Medicine 2008 Results – cardiac factors associated with revasc strategy

All Rights Reserved, Duke Medicine 2008 Results – comorbidities associated with revasc strategy

All Rights Reserved, Duke Medicine 2008 Limitations Single institution data Patient preferences Provider reasoning Anatomic details

All Rights Reserved, Duke Medicine 2008 Conclusions Temporal trends in treatment strategies demonstrate dramatic changes over time Decisions in CAD dominated by cardiac factors Comorbidities play a lesser role Most factors influencing treatment decisions appear stable over time

All Rights Reserved, Duke Medicine 2008 Factors associated with treatment decisions Revascularization vs. Medical therapy CharacteristicChi Square ValueP-value Ejection Fraction243.2<.0001 Duke CAD Class Severity131.5<.0001 CAD Duration92.0<.0001 Age72.9<.0001 Hx MI51.4<.0001 Race58.6<.0001 Recent MI (prior 6 weeks)45.6<.0001 NYHA Class67.8<.0001 Hx Cerebrovascular Disease29.7<.0001 Number of Diseased Vessels37.1<.0001 Diabetes Status29.9<.0001

All Rights Reserved, Duke Medicine 2008 Factors associated with treatment decision CABG vs. PCI CharacteristicChi Square ValueP-value Number of Diseased Vessels571.8<.0001 Left Main Disease209.2<.0001 Duke CAD Class Severity167.1<.0001 Recent MI (prior 6 weeks)42.9<.0001 Age34.4<.0001 Race31.1<.0001 Ejection Fraction30.2<.0001 BMI COPD Connective Tissue Disorder Diabetes Status

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