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Drug-Eluting Stents and the Use of Percutaneous Coronary Intervention Among Patients With Class I Indications for Coronary Artery Bypass Surgery Undergoing Index Revascularization

Analysis From the NCDR (National Cardiovascular Data Registry)

Andrew D. Frutkin, MD^_*, Jason B. Lindsey, MD^_*, Sameer K. Mehta, MD^_*, John A. House, MS^_*, John A. Spertus, MD, MPH^_*, David J. Cohen, MD, MSc^_*, John S. Rumsfeld, MD, PhD, Steven P. Marso, MD^_*,_* on behalf of the NCDR (National Cardiovascular Data Registry)

^_* Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
Denver Veteran's Affairs Medical Center, University of Colorado Health Sciences Center, Denver, Colorado

^_* Reprint requests and correspondence: Dr. Steven P. Marso, Mid America Heart Institute, University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, Missouri 64111 (Email: smarso{at}saint-lukes.org).

Objectives: Our purpose was to evaluate percutaneous coronary intervention (PCI) attempt rates in patients with class I indications for coronary artery bypass graft (CABG) surgery after the introduction of drug-eluting stents (DES).

Background: In patients with severe, multivessel coronary disease, CABG has historically been recommended over PCI. Practice guidelines for CABG were last updated before the emergence of data on DES efficacy.

Methods: We analyzed 265,028 procedures from the NCDR (National Cardiovascular Data Registry) meeting American College of Cardiology/American Heart Association class I indications for surgical revascularization. Temporal trends in PCI attempt rates were analyzed during 3 consecutive time periods: pre-DES (before April 1, 2003), DES diffusion (April 1, 2003 to December 31, 2004), and DES (January 1, 2005 to September 30, 2006).

Results: The attempted rate of PCI in patients with class I indications for CABG increased over the 3 time periods (pre-DES: 29.4%, DES diffusion: 33.4%, and DES era: 34.7%, p < 0.001). In a hierarchical multivariable logistic model adjusting for patient and PCI site characteristics, PCI attempts were more likely in the DES compared with pre-DES era (odds ratio: 1.44, 95% confidence interval: 1.40 to 1.48) and the DES diffusion era (odds ratio: 1.20, 95% confidence interval: 1.17 to 1.23). PCI attempt rates increased in all 3 time periods, although the average rate of increase during the DES era was 0.6% per quarter compared with 0.3% per quarter for both the DES diffusion and the pre-DES eras (p = 0.03).

Conclusions: DES use in clinical practice was associated with a significant overall increase in PCI to treat patients with class I indications for CABG. Long-term follow-up of this cohort of patients is warranted.

Key Words: percutaneous coronary intervention • coronary artery bypass grafting • drug-eluting stents

Abbreviations and Acronyms   BMS = bare-metal stent(s)   CABG = coronary artery bypass grafting   CAD = coronary artery disease   DES = drug-eluting stent(s)   LAD = left anterior descending coronary artery   MI = myocardial infarction   PCI = percutaneous coronary intervention

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