A study published in the February issue of JACC: Cardiovascular Interventions analyzed variation, predictors of variation, and associated clinical outcomes in revascularization of asymptomatic stable ischemic heart disease patients.
Researchers stratified patients with asymptomatic stable ischemic heart disease and obstructive coronary artery disease into two groups: those treated with revascularization or medical therapy. Hospitals were classified into tertiles based on their revascularization ratio. The primary outcomes were death and nonfatal myocardial infarction. Patients were excluded if they had Canadian Cardiovascular Society symptoms 1–4, non-obstructive coronary artery disease, in-patient angiogram, age < 20 years, or acute coronary syndrome.
Should revascularization be performed in asymptomatic patients w/ obstructive coronary artery disease? Retrospective observational cohort study in #JACCINT showed 2-fold variation in revascularization practices: https://t.co/nv6ShxCv9a pic.twitter.com/FOaLabIMA4
— JACC Journals (@JACCJournals) February 5, 2019
Final analysis included 9,897 patients, of whom 47% received medical therapy and 53% underwent revascularization. Researchers observed significant variations across hospitals in the ratio of revascularized to medically treated patients—a variation not attributed to patient, physician, or hospital factors (median odds ratio in null model: 1.25; median odds ratio in full model: 1.31).
Variation in Revascularization Practice and Outcomes in Asymptomatic Stable Ischemic Heart Disease https://t.co/Xe55Xm1BVx
— Taku Asano (@ta_brilliantsea) February 6, 2019
Despite the large variation in its use, though, revascularization was consistently found to be beneficial. Across revascularization ratio tertiles, the hazard ratio for death in revascularization patients was 0.81 (95% confidence interval: 0.69 to 0.96), and the hazard ratio for myocardial infarction was 0.58 (95% confidence interval: 0.46 to 0.73).
“Wide variation was observed in revascularization practice that was not explained by known factors,” the researchers wrote in their abstract. “Despite this variation, a clinical benefit was observed with revascularization that was consistent across hospitals.”
Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment https://t.co/GBeIfsAJtV
Maybe iFR is better than FFR? Maybe a firm data is needed.
— Dr. Professor Rajeev Gupta (@ProfessorRajeev) February 2, 2019
A different recent study compared two types of myocardial revascularization, percutaneous coronary intervention (PCI) and surgical coronary artery bypass graft intervention (CABG), for patients with coronary artery disease. The researchers found that both are “effective treatments.” PCI is associated with technological advances that make it an “attractive” option, but not all patients can undergo PCI and are therefore recommended for CABG. Therefore, these researchers concluded, “CABG still remains the best strategy for the treatment of multiple vessel [coronary artery disease] due to improved results in term of survival and freedom from reintervention.”
Clinical Pearls & Morning Reports: Learn about the Arterial Revascularization Trial. which randomly assigned patients to receive either bilateral internal-thoracic-artery grafts or a standard single left internal-thoracic-artery graft during CABG. https://t.co/3qZ6ZzhpRt pic.twitter.com/YaPJ2UpwM8
— NEJM Resident 360 (@NEJMres360) February 4, 2019