Temporal trends in percutaneous coronary intervention outcomes among older patients in the United States

Abstract

Background: New percutaneous coronary intervention (PCI) device technologies are often rapidly adopted into clinical practice, yet few studies have examined the overall impact of these new technologies on patient outcomes in community practice.

Methods: In hopes of determining temporal trends in PCI outcomes, we used data from the Centers for Medicare & Medicaid Service's Chronic Condition Warehouse (n = 3,250,836) by comparing patient characteristics and rates of 3-year major adverse cardiac events (MACE) across the balloon angioplasty (POBA) era (01/1991-09/1995), the bare metal stent (BMS) era (02/1998-04/2003), and the drug-eluting stent (DES) era (05/2004-10/2006). The adjusted association between era and outcomes was determined with Cox proportional hazards modeling (POBA era as reference).

Results: Compared with the POBA era, patients undergoing PCI were significantly older and had more medical comorbidities, and the risk for 3-year MACE was significantly lower during the BMS and DES eras (BMS vs. POBA adjusted HR [95% CI]: 0.930 [0.926-0.935]; DES vs. BMS: 0.831 [0.827-0.835]). Compared with males, the adjusted risk for 3-year MACE among females was lower during the POBA era, but slightly higher during the BMS and DES eras. Across all three eras, patients ≥75 years of age had higher adjusted risk for MACE compared with younger patients, and the risk for revascularization was lower for both females and older patients.

Conclusions: Despite its application in older and sicker Medicare beneficiaries, there has been a significant decrease in post-PCI MACE over time. The risk for death or myocardial infarction is higher among females and older patients compared with males and younger patients; therefore, future studies should focus on improving clinical outcomes in these high-risk subgroups.

Figure 1

Delineation of the POBA, BMS, and DES eras. Delineation of eras defined as ≥75% use of POBA, BMS, or DES, respectively.

Figure 2

Cumulative incidence rates of MACE, death, any MI, and revascularization. Cumulative incidence rates of MACE, death, any MI, and revascularization across the POBA, BMS, and DES eras at: A, One-year post index PCI. B, Two years post index PCI. C, Three years post index PCI. Global P values are presented.

Figure 3

Cumulative incidence rates of repeat PCI or CABG. Cumulative incidence rates of repeat PCI or CABG across the POBA, BMS, and DES eras at: A, One year post index PCI. B, Two years post index PCI. C, Three years post index PCI. Global P values are presented.