Predicting target vessel revascularization in older patients undergoing percutaneous coronary intervention in the drug-eluting stent era

• Published in: The American heart journal 2014-04, Vol.167 (4), p.576-584.e2
• Main Authors: Hess, Connie N., MD, MHS, Rao, Sunil V., MD, Dai, David, PhD, Neely, Megan L., PhD, Piana, Robert N., MD, Messenger, John C., MD, Peterson, Eric D., MD, MPH
• Format: Article
• Language: English
• Subjects: Acute coronary syndromes; Aged; Cardiovascular; Coronary Artery Disease - surgery; Coronary vessels; Coronary Vessels - surgery; Diabetes; Drug-Eluting Stents; Female; Follow-Up Studies; Heart attacks; Humans; Hypertension; Insulin; Male; Medicare; Patients; Percutaneous Coronary Intervention - methods; Prognosis; Retrospective Studies; Stents; Studies; Thrombosis; Treatment Outcome; Variables
• ISSN: 0002-8703; 1097-6744
• DOI: 10.1016/j.ahj.2013.12.017

Background The contemporary need for repeat revascularization in older patients after percutaneous coronary intervention (PCI) has not been well studied. Understanding repeat revascularization risk in this population may inform treatment decisions. Methods We analyzed patients ≥65 years old undergoing native-vessel PCI of de novo lesions from 2005 to 2009 discharged alive using linked CathPCI Registry and Medicare data. Repeat PCIs within 1 year of index procedure were identified by claims data and linked back to CathPCI Registry to identify target vessel revascularization (TVR). Surgical revascularization and PCIs not back linked to CathPCI Registry were excluded from main analyses but included in sensitivity analyses. Independent predictors of TVR after drug-eluting stent (DES) or bare-metal stent (BMS) implantation were identified by multivariable logistic regression. Results Among 343,173 PCI procedures, DES was used in 76.5% (n = 262,496). One-year TVR ranged from 3.3% (overall) to 7.1% (sensitivity analysis). Precatheterization and additional procedure-related TVR risk models were developed in BMS (c-indices 0.54, 0.60) and DES (c-indices 0.57, 0.60) populations. Models were well calibrated and performed similarly in important patient subgroups (female, diabetic, and older [≥75 years]). The use of DES reduced predicted TVR rates in high-risk older patients by 35.5% relative to BMS (from 6.2% to 4.0%). Among low-risk patients, the number needed to treat with DES to prevent 1 TVR was 63-112; among high-risk patients, this dropped to 28-46. Conclusions In contemporary clinical practice, native-vessel TVR among older patients occurs infrequently. Our prediction model identifies patients at low versus high TVR risk and may inform clinical decision making.