Author + information
- Received February 22, 2018
- Revision received May 15, 2018
- Accepted June 13, 2018
- Published online September 17, 2018.
- Kashish Goel, MDa,∗,
- Tanush Gupta, MDb,∗,
- Rajiv Gulati, MD, PhDa,
- Malcolm R. Bell, MDa,
- Dhaval Kolte, MD, PhDc,
- Sahil Khera, MD, MPHd,
- Deepak L. Bhatt, MD, MPHe,
- Charanjit S. Rihal, MD, MBAa and
- David R. Holmes Jr., MDa,∗ ()
- aMayo Clinic, Rochester, Minnesota
- bMontefiore Medical Center, Bronx, New York
- cBrown University, Providence, Rhode Island
- dMassachusetts General Hospital, Boston, Massachusetts
- eBrigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. David R. Holmes, Jr., Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905.
Objectives This study sought to assess temporal trends and outcomes of percutaneous coronary intervention (PCI) in nonagenarians.
Background With increasing life expectancy, nonagenarians requiring PCI are increasing even though outcomes data are limited.
Methods The National Inpatient Sample was used to identify all hospitalizations for PCI in patients aged ≥90 years from January 1, 2003, to December 31, 2014. The primary outcome was in-hospital mortality.
Results Nonagenarians (n = 69,271) constituted 0.9% of all PCI hospitalizations, increasing from 0.6% in 2003 to 2004 to 1.4% in 2013 to 2014 (ptrend < 0.001). From 2003–2004 to 2013–2014, the proportion of PCIs performed for ST-segment elevation myocardial infarction (STEMI) (23.1% to 30.9%) and non-ST-segment elevation acute coronary syndromes (49.6% to 52.6%) increased, whereas those for stable ischemic heart disease (SIHD) decreased (27.3% to 16.5%), respectively (ptrend < 0.001 for all). Overall in-hospital mortality after PCI for STEMI, non-ST-segment elevation acute coronary syndromes, and SIHD were 16.4%, 4.2%, and 1.8%, respectively. After multivariable risk adjustment for demographics, comorbidities, and hospital-level characteristics, in-hospital mortality remained unchanged in STEMI (odds ratio: 1.04; 95% confidence interval: 0.98 to 1.11; ptrend = 0.20) and non-ST-segment elevation acute coronary syndromes (odds ratio: 0.99; 95% confidence interval: 0.91 to 1.08; ptrend = 0.82), but increased in SIHD (odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44; ptrend = 0.04) from 2003 to 2004 to 2013 to 2014. The rates of bleeding and vascular complications decreased or remained stable in all 3 subgroups, whereas risk-adjusted incidence of stroke increased in patients with STEMI or SIHD.
Conclusions The rate of in-hospital mortality, major bleeding, vascular complications, and stroke after PCI in nonagenarians changed significantly from 2003 to 2014. This study provides a benchmark for discussion of PCI-related risks among physicians, patients, and families.
According to the latest U.S. census, there were more than 5 million individuals older than age 85 years in 2014, and this number is projected to double by 2035 (1). From 2000 to 2010, there was a 30.2% increase in the population of people age ≥90 years (2). This age group had the highest percentage increase among the elderly, group (>65 years). Coronary artery disease (CAD) is the most common cause of morbidity and mortality in the elderly, with most patients presenting with an acute coronary syndrome (ACS) (3). Cardiac catheterization and revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery is often indicated in patients with ACS. However, a large number of patients in this age group are denied the option of revascularization because of perceived increased risks related to comorbidities and advanced age (4,5). One of the main reasons for this may be paucity of data about the outcomes of PCI in this age group.
Despite the large number of patients older than 90 years of age, published data have been scarce on the in-hospital outcomes of PCI in nonagenarians, and the largest study to date included only 575 patients (6). In addition, it is unknown if there have been temporal changes in the number of PCIs and risk-adjusted outcomes in this population group in the contemporary era. We used the National Inpatient Sample (NIS) databases to assess the temporal trends and in-hospital outcomes after PCI in nonagenarians stratified by indication from 2003 to 2014.
Data were obtained from the 2003 to 2014 NIS databases. The NIS is the largest publicly available all-payer database of hospitalized patients in the United States and is sponsored by the Agency for Healthcare Research and Quality as a part of the Healthcare Cost and Utilization Project. The NIS includes data from all U.S. hospitals in participating states (n = 45) excluding rehabilitation and long-term acute care facilities, representing more than 96% of the U.S. population (7). Before 2012, the NIS included data on all discharges from a 20% sample of U.S. hospitals, stratified by census region, ownership, location, teaching status, and bed size. Beginning with 2012, the NIS includes data on a 20% sample of discharges from all Healthcare Cost and Utilization Project participating hospitals. For multiyear trend analyses including NIS data 2011 and earlier, a new set of revised weights called “trend weights” are provided to make estimates comparable with the new design beginning with 2012 data (7,8). The detailed information about NIS dataset has been described previously (9). This study was exempt from institutional review board approval because a deidentified administrative database was used. We adhered strictly to the NIS survey methodology on data interpretation, research design, and data analysis as described by Healthcare Cost and Utilization Project (7) and recently highlighted by Khera et al. (10).
From 2003 to 2014, a total of 93,374,095 records were included in the NIS, corresponding to a national estimate of 459,384,143 hospital discharges in the United States. We used the International Classification of Diseases-9th Edition-Clinical Modification (ICD-9-CM) procedure codes 00.66, 36.01, 36.02, 36.05, 36.06, 36.07, and 17.55 to identify all hospitalizations for PCI in patients aged ≥18 years (n = 7,881,212). Patients aged ≥90 years were then included in the present analysis (n = 69,313). Beginning with 2012, ages older than 89 were aggregated into a single category of ≥90 years in NIS (11). Records with missing data on in-hospital mortality or length of stay (LOS) were excluded (n = 41), giving us the final study cohort of 69,271 hospitalizations in nonagenarians undergoing PCI. We used ICD-9-CM diagnosis codes to identify patients undergoing PCI for ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation acute coronary syndromes (NSTEACS), or stable ischemic heart disease (SIHD) (Online Table 1). We also identified all nonagenarians with a primary or secondary discharge diagnosis of STEMI or NSTEACS to determine the proportion of patients with ACS not undergoing PCI.
Patient and hospital characteristics
Baseline patient characteristics included were: demographics (sex, race, primary expected payer), weekend admission, and clinically relevant comorbidities (dyslipidemia, known CAD, prior myocardial infarction, prior PCI, prior coronary artery bypass grafting, atrial fibrillation, heart failure, diabetes mellitus, hypertension, peripheral vascular disease, chronic renal failure, anemia, chronic pulmonary disease, coagulopathy, hypothyroidism, fluid and electrolyte disorders, and neurological disorders) (12). Hospital characteristics included geographic region, bed size, location, and teaching status. Procedural characteristics included stent type (bare-metal stent, drug-eluting stent, or balloon angioplasty alone), multivessel PCI, and use of mechanical circulatory support. The ICD-9-CM codes used to identify comorbidities and procedural characteristics are provided in Online Table 1.
Our primary outcome of interest was all-cause in-hospital mortality. Secondary outcomes were bleeding, vascular complications, stroke, and average LOS. The ICD-9-CM codes used to identify in-hospital complications are provided in Online Table 1. Prior studies using administrative data have used this methodology to identify the included secondary outcomes (9,13).
Weighted estimates were obtained by applying trend weights to the unweighted discharge data and were used for all analyses. Survey methodology was used for all analyses to account for clustering and stratification of hospitalizations in the NIS as recommended by the Agency for Healthcare Research and Quality (10,14,15). For trend analyses, the study period was divided into 2-year time intervals. Temporal trends in baseline characteristics and indication for PCI were examined using the Cochrane-Armitage test. In-hospital outcomes were examined separately in STEMI, NSTEACS, and SIHD groups. To determine if in-hospital outcomes changed over time, we used complex samples multivariable logistic or linear regression models. The 2-year time intervals were included as a continuous variable in the regression models.
Variables included in the regression models included demographics (sex, race, primary payer), weekend admission, hospital characteristics, and clinically relevant comorbidities. Besides the aforementioned variables, we additionally adjusted for the presence of cardiogenic shock in the STEMI and NSTEACS subgroups. Data were complete on all variables except primary payer (<0.1% missing), hospital characteristics (0.4% missing), comorbidities (0.4% missing), and race (17.5% missing). For variables with <5% missing data, the missing values were replaced with the dominant category. For variables with >5% missing data (only race), the missing value was treated as a separate category in the regression models. Because LOS had a positively skewed distribution, log transformation of LOS was used as the dependent variable in the linear regression models. We also compared the in-hospital outcomes of nonagenarians with STEMI or NSTEACS undergoing PCI versus conservative management. Lastly, we identified independent predictors of in-hospital mortality in patients undergoing PCI for STEMI, NSTEACS, or SIHD.
Statistical analysis was performed using SPSS Statistics version 21.0 (IBM Corp., Armonk, New York). Categorical variables are expressed as percentage and continuous variables as mean ± SD. Odds ratio (OR) and 95% confidence interval (CI) are used to report the results of regression analyses. All p values are 2-sided with a significance threshold of p < 0.05.
A total of 69,271 hospitalizations for PCI in nonagenarians in the United States were recorded from 2003 to 2014. These constituted 0.9% of all PCI hospitalizations during the study period. Most of the patients were females (57.2%) and white (72.3%) (Table 1). PCI was performed for STEMI in 27.9% of the patients, for NSTEACS in 49.8%, and SIHD in 22.2%.
Among hospitalized nonagenarians with ACS during the study period (n = 794,278), only 6.8% (n = 53,878) underwent PCI. The differences in baseline characteristics of nonagenarians with ACS undergoing versus not undergoing PCI are presented in Online Table 2. Compared with patients undergoing conservative management, those treated with PCI were more likely to have known CAD or prior coronary revascularization and less likely to have comorbid conditions, such as heart failure, chronic pulmonary diseases, dementia, and neurological disorders.
The number of nonagenarians undergoing PCI increased significantly from 9,404 in 2003 to 2004 (0.6% of all PCIs) to 13,265 in 2013 to 2014 (1.4% of all PCIs; ptrend < 0.001) (Figure 1). Of all hospitalized nonagenarians with STEMI or NSTEACS, the proportion of those undergoing PCI increased from 5.4% to 19.5% for the STEMI and from 5.4% to 6.3% for NSTEACS (ptrend < 0.001 for both) (Figure 2).
Online Table 3 summarizes the temporal trends in distribution of demographics, risk factors, and procedural characteristics from 2003 to 2014. The prevalence of all comorbidities including dyslipidemia, prior myocardial infarction, prior PCI, prior coronary artery bypass graft, atrial fibrillation, heart failure, diabetes mellitus, hypertension, peripheral vascular disease, and chronic renal failure increased significantly over the study period.
Of all inpatient PCIs in nonagenarians, the proportion of those performed for STEMI increased from 23.1% to 30.9% and for NSTEACS increased from 49.6% to 52.6%, whereas that for SIHD decreased from 27.3% to 16.5% (ptrend < 0.001) (Figure 3). Procedurally, the use of drug-eluting stents and multivessel PCI also increased during the study period. There was an increase in the proportion of patients with cardiogenic shock in patients undergoing PCI for STEMI (from 9.9% to 17.8%) and NSTEACS (from 1% to 4.5%) during the study period (ptrend < 0.001 for both) (Figure 4). The use of mechanical circulatory support devices increased from 3.8% to 5.7% (ptrend < 0.001).
Of 180,486 patients hospitalized with STEMI from 2003 to 2014, only 19,349 (10.7%) underwent PCI. The overall in-hospital mortality after PCI and conservative management was 16.4% and 33.5%, respectively. After multivariable risk adjustment, PCI was associated with lower in-hospital mortality compared with conservative management (adjusted OR: 0.35; 95% CI: 0.31 to 0.38; p < 0.001). PCI was also associated with lower incidence of in-hospital stroke and shorter LOS, whereas vascular complications were expectedly higher in the PCI cohort (Online Table 4).
There was an absolute increase of 3.7% in in-hospital mortality in STEMI patients undergoing PCI from 13.8% in 2003 to 2004 to 17.5% in 2013 to 2014. However, after adjustment for demographics, risk factors, procedural characteristics, and cardiogenic shock, there was no change in the in-hospital mortality over the study period (adjusted OR: 1.04; 95% CI: 0.98 to 1.11; ptrend = 0.20). There was a significant increase in the incidence of in-hospital stroke that persisted after risk adjustment (0.4% in 2003 to 2004 to 2.1% in 2013 to 2014; unadjusted OR: 1.28; 95% CI: 1.10 to 1.49; adjusted OR: 1.21; 95% CI: 1.02 to 1.44). The unadjusted and adjusted rates of major bleeding and vascular complications were unchanged, whereas the average LOS decreased during the study period (Table 2).
Of 613,792 patients hospitalized with NSTEACS during the study period, 34,529 (5.6%) underwent PCI. PCI was associated with a significant reduction in in-hospital mortality after adjustment for demographics, hospital characteristics, comorbidities, and cardiogenic shock (3.7% vs. 12.8%; adjusted OR: 0.26; 95% CI: 0.23 to 0.29; p < 0.001). PCI was also associated with a lower incidence of major bleeding, stroke, and shorter LOS, but with increased odds of vascular complications (Online Table 4).
Among nonagenarians undergoing PCI for NSTEACS, the absolute incidence of in-hospital mortality and major bleeding remained unchanged during the study period, that of vascular complications decreased, and that of stroke increased. There was no significant change in the direction of these trends after risk adjustment. Average LOS decreased during the study period (Table 2).
The overall in-hospital mortality for nonagenarians undergoing PCI for SIHD was 1.8%. There was a significant increase in absolute in-hospital mortality from 1.2% (2003 to 2004) to 3.9% (2013 to 2014), which was significant even after multivariable risk adjustment (adjusted OR: 1.21; 95% CI: 1.01 to 1.44; ptrend = 0.04). There was no significant change in the incidence of bleeding or vascular complications and average LOS. Risk-adjusted incidence of stroke increased during the study period (Table 3).
Among patients surviving to hospital discharge, 69.4% with SIHD, 58% with NSTEACS, and 42.6% with STEMI were discharged home. One-third of the STEMI patients (33.6%) were discharged to a skilled nursing facility in contrast to 14.5% with SIHD and 22% with NSTEACS (Figure 5).
Predictors of in-hospital mortality
The independent predictors of in-hospital mortality among nonagenarians undergoing PCI for STEMI, NSTEACS, or SIHD are reported in Online Tables 5 to 7. Baseline comorbid conditions predicted in-hospital mortality in all 3 study groups. In addition, cardiogenic shock was associated with higher in-hospital mortality in those undergoing PCI for STEMI or NSTEACS.
In this largest study to date of approximately 70,000 nonagenarians undergoing PCI from 2003 to 2014 in the United States, we report the following important findings: 1) the proportion of PCIs performed for ACS increased, whereas those for SIHD decreased; 2) in those undergoing PCI for STEMI, there was a temporal increase in in-hospital mortality that could be entirely explained by worsening baseline risk profile; 3) in-hospital mortality in nonagenarians undergoing PCI for NSTEACS remained unchanged; 4) there was a temporal increase in-hospital mortality in those undergoing PCI for SIHD that persisted after risk adjustment; and 5) bleeding and vascular complications decreased or remained stable in all study groups.
Because CAD is the most common cause of morbidity and mortality in the elderly, increasingly more nonagenarians are presenting to the hospital for ACS and are treated invasively. However, studies evaluating outcomes of PCI in nonagenarians have been limited by small numbers, not allowing for stratified analysis by indication of PCI because in-hospital outcomes vary in STEMI, NSTEACS, and SIHD. In the largest meta-analysis of 10 studies including 575 nonagenarians undergoing PCI for all indications, Presutti et al. (6) reported a 12.6% rate of in-hospital mortality and 16.4% risk of in-hospital major adverse cardiovascular events. Other single-center studies including fewer than 200 patients have reported similar results; however, they have been limited by small numbers (16,17). A recently published study from all PCIs in the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) program reported increasing frequency of PCI in 274 nonagenarians (18). However, the authors did not report the trends specifically in nonagenarians. The incidence of cardiogenic shock rate was only 2.6%, reflecting a relatively lower-risk population compared with our study, and most nonagenarians undergoing PCI had a non-ACS “other” indication compared with our study that included predominantly patients with ACS. Also, females constituted only 1.8% of the study population in the VA study, therefore not reflecting the trends and outcomes of non-VA nonagenarians.
The present study adds to the previously published small studies and is the first study to date presenting outcomes and trends of PCI stratified by indication in a nationally representative cohort. We found that nonagenarians constitute 0.9% of all PCIs performed in the United States during from 2003 to 2014. More than three-fourths of the PCIs were performed for ACS, the proportion of which increased during the study years. The risk profile of patients undergoing PCI in recent years was significantly worse compared with those in 2003 to 2004, reflecting the higher risk patient population undergoing PCI in the contemporary era (7,10).
Very limited data are available regarding the management of STEMI in nonagenarians. A previous study reported approximately 25% in-hospital mortality in nonagenarians hospitalized with STEMI (19). In our study, in-hospital mortality in nonagenarians with STEMI was 16.4% in those undergoing PCI versus 33.5% in those managed conservatively. After multivariable risk adjustment, PCI was associated with 65% lower risk odds of in in-hospital mortality. However, only 10.7% of all nonagenarians with STEMI underwent PCI. Although this proportion increased during the study period, the use of PCI in this population remains exceedingly low.
Among patients undergoing PCI for STEMI, there was an absolute increase in in-hospital mortality from 13.8% to 17.5% from 2003 to 2014. After risk adjustment for worsening baseline risk profile, this increasing trend in in-hospital mortality was no longer significant. We also observed an increase in the proportion of cardiogenic shock from 9.9% in 2003 to 2004 to 18.8% in 2013 to 2014 among these patients reflecting the current trends in offering PCI to higher risk patients. There was an increasing trend in the incidence of in-hospital stroke from 0.4% to 2.1% during the study period, which persisted after risk adjustment. This finding is hard to explain but is likely caused by the inability to fully account for increasing acuity of patients over the years because of lack of availability of data on hemodynamic parameters and acute metabolic derangements. Approximately 35% of the patients undergoing PCI for STEMI who survived the hospitalization required a skilled nursing facility or short-term hospital likely due to the high prevalence of frailty necessitating skilled assistance at discharge after a catastrophic event such as STEMI. These data suggest that revascularization in nonagenarians presenting with STEMI should be considered, keeping in mind the high risk of procedural and post-procedural complications. Future studies should focus on identification of appropriate patients who are likely to benefit the most from urgent revascularization.
Most of the PCIs in nonagenarians were performed for NSTEACS. Of all nonagenarians with a discharge diagnosis of NSTEACS, only 5.6% of the patients underwent PCI with only a small absolute increase from 5.4% to 6.3% during the study period. One randomized clinical trial in NSTEACS patients older than 80 years showed that an early invasive strategy was associated with a significant reduction in the composite of myocardial infarction, need for urgent revascularization, stroke, or death during follow-up (20). Even in our study, PCI was associated with lower odds of in-hospital mortality and more favorable secondary outcomes in nonagenarians with NSTEACS. However, the use of an invasive strategy and revascularization in elderly patients presenting with NSTEMI remains low (4,5,21), presumably because of perceived risks associated with an invasive strategy. Our study adds to the literature and provides data on in-hospital complications of PCI in a large number of nonagenarians admitted with NSTEACS. The overall mortality in this subgroup was 4.1%. The risk-adjusted incidence of in-hospital mortality, major bleeding, and stroke remained unchanged, and that of vascular complications decreased over time, probably related to safer vascular access practices and improving operator experience and technology. This study adds to the previous small studies indicating that an invasive approach for NSTEACS is feasible with a relatively low risk of complications in nonagenarians and suggests that revascularization with PCI should not be withheld in this high-risk population (4,5,21).
The prevalence of coronary calcification and high-risk complex lesions increases with age, and therefore, elective PCI in nonagenarians may be high risk. There was a decline in the proportion of PCIs performed for SIHD over the study period. In-hospital mortality increased from 1.2% in 2003 to 3.9% in 2014, which persisted after risk adjustment. This trend is mostly related to the increased in-hospital mortality noted in 2013 to 2014. The specific reason for this increase in mortality is difficult to decipher because of the lack of data on the type and complexity of lesions treated, left ventricular function, and cause of mortality in the NIS database. The risk of bleeding and vascular complications remained unchanged during the study period. These data underscore the importance of patient selection, appropriate risk-mitigating techniques, and treatment of only appropriate lesions in this high-risk age group. There are no comparative data available from any previous studies in this subset of the patients undergoing PCI.
This is a retrospective study of nonagenarians undergoing an inpatient PCI. Hence, it is subject to an inherent selection bias because those deemed candidates for PCI likely represent a lower-risk cohort in whom the patients, their families, and the treating physicians perceived that the purported benefits of an invasive strategy outweighed the associated risks. As such, the outcomes of PCI reported in our study might be different if PCI was offered to all nonagenarians with an appropriate indication. However, because patients older than 90 years of age are often excluded from randomized clinical trials, national registries are possibly the best way to assess outcomes in this age group. Outpatient PCIs are not included in the NIS (9). However, this study likely represents most of the PCIs performed in nonagenarians in the United States because they either present with ACS or are likely to be hospitalized after PCI because of the substantial risk of post-procedural complications. The proportion of SIHD patients who do not undergo PCI could not be determined because these patients would typically not be hospitalized and thus not be captured in the NIS. Beginning with 2012, patients older than 89 years were aggregated into a single category of ≥90 years to maintain patient confidentiality. Therefore, we could not report the specific age indices of our study population (11). Detailed angiographic and complication data were not available, which may add insights into the mechanism of complication and guide patient selection. Data were extracted based on ICD-9-CM codes, and the accuracy of data is subject to the training and expertise of coders. It is possible that the increased rate of cardiogenic shock is related to overcoding in the recent years. Data on recurrent ischemia, target vessel revascularization, repeat hospitalization, symptom relief, or mortality during follow-up were not available because NIS only reports in-hospital data. Individual records represent PCI-related hospitalizations and not unique patients.
In this largest study to date of approximately 70,000 PCI-related hospitalizations in nonagenarians, we found significant changes in the absolute rates of in-hospital mortality, major bleeding, vascular complications, and stroke from 2003 to 2014. These variations were most likely a result of worsening baseline clinical risk profile and procedural factors. This study provides a benchmark for the rate of in-hospital complications associated with PCI in nonagenarians presenting with ACS and SIHD. These data provide a starting point for discussions among patients, families, and physicians but may underestimate the true risks and benefits of PCI in nonagenarians previously not thought to be candidates for PCI.
WHAT IS KNOWN? The population of the United States is aging; however, the largest study evaluating outcomes of PCI in nonagenarians included only 570 patients.
WHAT IS NEW? In this large retrospective analysis of all hospitalizations for PCI in nonagenarians in the United States from 2003 to 2014, risk-adjusted in-hospital mortality did not change in STEMI and NSTEACS patients after adjusting for demographics, comorbidities, and hospital and procedural characteristics. Risk-adjusted in-hospital mortality increased in patients with SIHD.
WHAT IS NEXT? Future studies should evaluate the long-term outcomes of PCI stratified by indication in nonagenarians and focus on identification of appropriate patients who are likely to benefit the most from percutaneous revascularization.
↵∗ Drs. Goel and Gupta contributed equally to this work.
Dr. Deepak L. Bhatt serves on the Advisory Board for Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; is on the Board of Directors for Boston VA Research Institute, and Society of Cardiovascular Patient Care; is Chair of American Heart Association Quality Oversight Committee; serves on Data Monitoring Committees of Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute), Cleveland Clinic, Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, and Population Health Research Institute; has received honoraria from American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice-Chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; clinical trial steering committee), Belvoir Publications (Editor-in-Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), HMP Global (Editor-in-Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), and WebMD (CME steering committees); has a relationship with Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), and VA CART Research and Publications Committee (Chair); received research funding from Abbott, Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Idorsia, Ironwood, Ischemix, Lilly, Medtronic, PhaseBio, Pfizer, Regeneron, Roche, Sanofi, Synaptic, and The Medicines Company; received royalties from Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); is Site Co-Investigator for Biotronik, Boston Scientific, St. Jude Medical (now Abbott), and Svelte; is a Trustee of American College of Cardiology; and received unfunded research from FlowCo, Merck, PLx Pharma, and Takeda. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- acute coronary syndrome(s)
- coronary artery disease
- confidence interval
- International Classification of Diseases-9th Edition-Clinical Modification
- length of stay
- National Inpatient Sample
- non-ST-segment elevation acute coronary syndrome(s)
- odds ratio
- percutaneous coronary intervention
- stable ischemic heart disease
- ST-segment elevation myocardial infarction
- Received February 22, 2018.
- Revision received May 15, 2018.
- Accepted June 13, 2018.
- 2018 American College of Cardiology Foundation
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