Temporal trends in the utilization and outcomes of percutaneous coronary interventions in patients with liver cirrhosis

Abstract

Objectives: We sought to assess the national trends in the utilization and outcomes of percutaneous coronary interventions (PCI) in patients with cirrhosis. Background: Contemporary data on PCI in patients with liver cirrhosis are limited. Methods: The National-Inpatient-Sample was used to identify patients who underwent PCI between 2003 and 2016. We examined the annual PCI rate, and compared the in-hospital morbidity, mortality, resource utilization, and cost following PCI in patients with and without cirrhosis. Results: A total of 8,860,178 PCI hospitalizations were identified, of those, 20,339 (0.2%) were performed in patients with cirrhosis. Annual PCI rates decreased overtime in patients without liver cirrhosis but increased in those with cirrhosis (P trend < .001). Patients with cirrhosis had a characteristic clinical, demographic, and socioeconomic profile compared with those without cirrhosis. The use of bare-metal stents decreased from 69.1 to 11.4% in the noncirrhosis group, and from 81.9 to 21.3% in the cirrhosis group. Compared with propensity-matched patients without cirrhosis, PCI in cirrhotic patients was associated with higher in-hospital mortality across all indications (STEMI 19.1 vs. 11.5%, p = .002; NSTEMI 8.7 vs. 5.6%, p = .002; and UA/SIHD 7.7 vs. 4.3%, p < .001). Cirrhotic patients also had significantly higher rates of acute kidney injury, but similar rates of vascular complications and stroke. Additionally, cirrhotic patients had longer hospitalizations, were less likely to be discharged home, and accrued higher cost across all PCI indications. Conclusions: Patients with cirrhosis who are deemed "suitable PCI candidates" in current practice remain at high-risk for worse short-term morbidity and mortality, and higher cost of care. Fahad Alqahtani and Sudarashan Balla contributed equally to the manuscript.

Trends in Characteristics and Outcomes of Hospital Inpatients Undergoing Coronary Revascularization in the United States, 2003-2016

“…The NIS has been used extensively to assess national trends in the utilization, disparities, and outcomes of coronary artery interventions. [13][14][15][16][17][18][19]…”

Coronary interventions among patients with hepatic insufficiency: Encouragement to avoid a jaundiced view

“…Alqahtani et al report on the temporal trend and outcomes of PCI among patients with underlying cirrhosis over a 13-year period from the National Inpatient Sample (NIS). 2 The authors note that patients with cirrhosis account for a small proportion (0.2%) of all PCI and observed a temporal increase in the rate of PCI among this cohort for both acute coronary syndromes and stable ischemic heart disease. In a propensity-matched analysis, cirrhotic patients undergoing PCI were at higher risk for acute kidney injury, required greater resource allocations, and incurred larger cost during index hospitalization.…”

“…While the current report by Alqahtani et al highlights the temporal decrease in utilization rates for bare-metal stents in both cirrhotic (81.9 to 21.3%) and non-cirrhotic (69.1 to 11.4%) patients, this rate remains higher than expected. 2 Based on the data provided, it would suggest that a cirrhotic patient undergoing PCI is roughly twice as likely to receive a bare-metal stent as their non-cirrhotic counterpart is. This could be interpreted as an effort on the part of clinicians to mitigate the perceived bleeding risk that accompanies chronic hepatic insufficiency.…”

“…In this issue of Catheterization and Cardiovascular Interventions , Alqahtani et al report on the temporal trend and outcomes of PCI among patients with underlying cirrhosis over a 13‐year period from the National Inpatient Sample (NIS) 2 . The authors note that patients with cirrhosis account for a small proportion (0.2%) of all PCI and observed a temporal increase in the rate of PCI among this cohort for both acute coronary syndromes and stable ischemic heart disease.…”

“…In a similar observational study, bare‐metal stents were associated with increased in‐hospital mortality (4.7 vs. 2.6%) compared with drug‐eluting stents in a propensity matched cohort of patients with cirrhosis. Furthermore, cirrhotic patients do not appear to incur an increased risk for vascular access complications in any of these studies 1‐3 . Given randomized controlled trial data demonstrating the superiority of zotarolimus‐eluting stents over bare‐metal stents among patients with high bleeding risk, the findings by Alqahtani et al may represent a fallacious avoidance of contemporary technology in patients with cirrhosis 4 .…”