Ralf E Harskamp1, Tracy Y Wang2, Deepak L Bhatt3, Stephen D Wiviott4, Ezra A Amsterdam5, Shuang Li2, Laine Thomas2, Robbert J de Winter6, Matthew T Roe7. 1. Duke Clinical Research Institute, Durham, NC; Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. 2. Duke Clinical Research Institute, Durham, NC. 3. Veterans Affairs Boston Healthcare System, Boston, MA; TIMI Study Group, Boston, MA; Brigham and Women's Hospital and Harvard Medical School, Boston, MA. 4. TIMI Study Group, Boston, MA; Brigham and Women's Hospital and Harvard Medical School, Boston, MA. 5. University of California Davis Medical Center, Sacramento, CA. 6. Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. 7. Duke Clinical Research Institute, Durham, NC. Electronic address: matthew.roe@duke.edu.
Abstract
BACKGROUND: Patients with non-ST-elevation myocardial infarction (NSTEMI) and three-vessel or left main coronary disease (3VD/LMD) have a high risk of long-term mortality when treated with a medical management strategy (MMS) compared with revascularization. METHODS: We evaluated patterns of use and patient features across United States hospitals designated by MMS for NSTEMI patients with 3VD/LMD included in the ACTION Registry-GWTG from 2007-2012. RESULTS: A total of 42,535 patients without prior bypass surgery were found to have 3VD (≥50% stenosis in all major coronary vessels) or LMD (≥50% lesion) during in-hospital angiography at 423 hospitals with percutaneous and surgical revascularization capabilities. Hospitals (n = 316) with an adequate volume (≥25 NSTEMI patients treated) were stratified into tertiles defined by use of MMS; differences in patient characteristics and outcomes were analyzed. The proportion of NSTEMI patients treated with MMS at all hospitals varied from 16% to 19% each quarter and did not change significantly from 2007 to 2012 (P trend = .11). Among hospitals with adequate volume, the proportion of patients treated with MMS also varied widely (median 17.1%, range: 0.0-44.8%, P < .0001). Patient baseline characteristics, predicted mortality risk, actual in-hospital mortality rates, and discharge treatments were similar across hospital tertiles. CONCLUSIONS: Close to 20% of patients with NSTEMI and 3VD/LMD identified during in-hospital angiography are treated with MMS without revascularization in contemporary practice. Since the use of MMS varies widely across hospitals despite a relatively similar hospital-level case mix, these findings suggest that there is no standard threshold for the use of revascularization in NSTEMI patients with 3VD/LMD.
BACKGROUND:Patients with non-ST-elevation myocardial infarction (NSTEMI) and three-vessel or left main coronary disease (3VD/LMD) have a high risk of long-term mortality when treated with a medical management strategy (MMS) compared with revascularization. METHODS: We evaluated patterns of use and patient features across United States hospitals designated by MMS for NSTEMIpatients with 3VD/LMD included in the ACTION Registry-GWTG from 2007-2012. RESULTS: A total of 42,535 patients without prior bypass surgery were found to have 3VD (≥50% stenosis in all major coronary vessels) or LMD (≥50% lesion) during in-hospital angiography at 423 hospitals with percutaneous and surgical revascularization capabilities. Hospitals (n = 316) with an adequate volume (≥25 NSTEMIpatients treated) were stratified into tertiles defined by use of MMS; differences in patient characteristics and outcomes were analyzed. The proportion of NSTEMIpatients treated with MMS at all hospitals varied from 16% to 19% each quarter and did not change significantly from 2007 to 2012 (P trend = .11). Among hospitals with adequate volume, the proportion of patients treated with MMS also varied widely (median 17.1%, range: 0.0-44.8%, P < .0001). Patient baseline characteristics, predicted mortality risk, actual in-hospital mortality rates, and discharge treatments were similar across hospital tertiles. CONCLUSIONS: Close to 20% of patients with NSTEMI and 3VD/LMD identified during in-hospital angiography are treated with MMS without revascularization in contemporary practice. Since the use of MMS varies widely across hospitals despite a relatively similar hospital-level case mix, these findings suggest that there is no standard threshold for the use of revascularization in NSTEMIpatients with 3VD/LMD.
Authors: Babatunde A Yerokun; Judson B Williams; Jeffrey Gaca; Peter K Smith; Matthew T Roe Journal: Coron Artery Dis Date: 2016-06 Impact factor: 1.439
Authors: Ajay J Kirtane; Darshan Doshi; Martin B Leon; John M Lasala; E Magnus Ohman; William W O'Neill; Adhir Shroff; Mauricio G Cohen; Igor F Palacios; Nirat Beohar; Nir Uriel; Navin K Kapur; Dimitri Karmpaliotis; William Lombardi; George D Dangas; Manish A Parikh; Gregg W Stone; Jeffrey W Moses Journal: Circulation Date: 2016-08-02 Impact factor: 39.918