Using the Risk of Restenosis as a Guide to Triaging Patients Between Surgical and Percutaneous Coronary Revascularization

Abstract

Background-Coronary artery bypass graft (CABG) and percutaneous coronary revascularization (PCI) are strategies for treating coronary disease. Because the principal limitation of PCI is restenosis, CABG might be favored for those at high risk for restenosis. Using a clinical risk score for predicting restenosis, we examined whether patients with higher risks for restenosis were preferentially referred for CABG. Methods and Results-A procedural registry of 2320 revascularization patients from whom data on procedure type, demographics, comorbid conditions, health status, vessel anatomy, and outcomes were taken was analyzed. Patients were classified and scored into 3 categories of restenosis risk ranging from 11% to 44%, as defined by 8 preprocedural characteristics. The objective of this study was to describe referral patterns between PCI and CABG in each category of risk. 2060 patients underwent nonemergent revascularization. 1404 of the patients underwent PCI and 656 were treated with CABG. Among the patients at low and intermediate risk for restenosis, twice as many were referred to PCI. Among those at the highest risk, 3-times as many were referred to PCI, resulting in a significant trend for those with the higher risks of restenosis to be preferentially referred to PCI (Pϭ0.015). Similar results were seen when the analysis was restricted to only those with multivessel disease. Conclusions-Patients at higher risk for restenosis were being preferentially treated with PCI as opposed to CABG. These results may have implications for reevaluating current patterns of triaging patients between PCI and CABG, and for the use of drug-eluting stents within PCI patients.

Implementing an innovative consent form: the PREDICT experience

“…Confidence in the restenosis models was even more difficult to achieve. Even though pre-procedural models are just as good in predicting restenosis as models that incorporate the results of the angiogram [ 20 , 21 ], the interventionalists did not readily accept this. Comments were made such as 'there is so much important data gained from the angiogram...that in many ways neutralizes the true effectiveness of the PREDICT consent form' and 'the estimates of restenosis are helpful, however, I think (at least I) incorporate many of the clinical drivers already into my decision of which stent to use.'…”

“…A multidisciplinary team developed four separate pre-procedural risk models for percutaneous coronary intervention (PCI), through access to large cardiovascular databases and collaboration with national colleagues: in-hospital mortality following PCI [ 19 ], bleeding complications following PCI [ 20 ], and one-year restenosis with bare metal and drug-eluting stents [ 21 ] (Appendix). Technology using the patient experience, complete with patient characteristics, clinical data, procedural data, and treatment options with predicted outcomes for each different selected treatment modality has been developed [ 25 - 27 ].…”

Identification of independent risk factors for restenosis following bare-metal stent implantation: Role of bare-metal stents in the era of drug-eluting stents

“…Kettlekamp et al (17) used the Mid America Heart Institute (MAHI) restenosis risk model (18) to predict restenosis. The authors used clinical variables and the frequency of angina in the prediction, although they did not use angiographic variables, and compared the current referral patterns of patients requiring coronary revascularization to PCI or bypass graft as a function of the underlying risk for restenosis.…”

Converting the Informed Consent From a Perfunctory Process to an Evidence-Based Foundation for Patient Decision Making

“…13,15 In brief, after design and construction of the technological framework, statistical predictive models were rigorously developed for 4 potential outcomes of PCI (periprocedural bleeding risks, 16 mortality, 17 and clinical restenosis with a BMS or DES 18 ). These 4 outcomes were selected on the basis of their value to patients and clinicians in setting realistic expectations for the outcomes of the procedure and for their potential to help guide clinical decision making (eg, the type of stent to deploy).…”