Contemporary Management Before Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

IF 6.9 2区 医学
Stanley A Swat, Annika Hebbe, Mary E Plomondon, Ki E Park, Rory S Bricker, Stephen W Waldo, Javier A Valle
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引用次数: 0

Abstract

Background: Guidelines recommend maximal antianginal medical therapy before attempted coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The degree to which this occurs in contemporary practice is unknown. We aimed to characterize the frequency and variability of preprocedural use of antianginal therapy and stress testing within 3 months before PCI of CTO (CTO PCI) across a nationally integrated health care system.

Methods: We identified patients who underwent attempted CTO PCI from January 2012 to September 2018 within the Veterans Affairs Healthcare System. Patients were categorized by management before CTO PCI: presence of ≥2 antianginals, stress testing, and ≥2 antianginals and stress testing within 3 months of PCI attempt. Multivariable logistic regression and inverse propensity weighting were used for adjustment before trimming, with median odds ratios calculated for variability estimates.

Results: Among 4250 patients undergoing attempted CTO PCI, 40% received ≥2 antianginal medications and 24% underwent preprocedural stress testing. The odds of antianginal therapy with more than one medication before CTO PCI did not change over the years of the study (odds ratio [OR], 1.0 [95% CI, 0.97-1.04]), whereas the odds of undergoing preprocedural stress testing decreased (OR, 0.97 [95% CI, 0.93-0.99]), and the odds of antianginal therapy with ≥2 antianginals and stress testing did not change (OR, 0.98 [95% CI, 0.93-1.04]). Median odds ratios (MOR) showed substantial variability in antianginal therapy across hospital sites (MOR, 1.3 [95% CI, 1.26-1.42]) and operators (MOR, 1.35 [95% CI, 1.26-1.63]). Similarly, preprocedural stress testing varied significantly by site (MOR, 1.68 [95% CI, 1.58-1.81]) and operator (MOR, 1.80 [95% CI, 1.56-2.38]).

Conclusions: Just under half of patients received guideline-recommended management before CTO PCI, with significant site and operator variability. These findings suggest an opportunity to reduce variability in management before CTO PCI.

慢性全闭塞经皮冠状动脉介入治疗前的当代管理:退伍军人事务临床评估、报告和跟踪计划的启示》。
背景:指南建议,在尝试冠状动脉慢性全闭塞(CTO)经皮冠状动脉介入治疗(PCI)之前,应最大限度地使用抗心绞痛药物治疗。但在当代实践中的应用程度尚不清楚。我们的目的是描述一个全国性综合医疗系统在 CTO PCI(CTO PCI)术前 3 个月内使用抗心绞痛治疗和压力测试的频率和变异性:我们确定了退伍军人事务医疗保健系统内 2012 年 1 月至 2018 年 9 月期间尝试进行 CTO PCI 的患者。患者按 CTO PCI 前的管理进行分类:存在≥2 个反向血管、进行过压力测试,以及在尝试 PCI 后 3 个月内存在≥2 个反向血管并进行过压力测试。采用多变量逻辑回归和反倾向加权法进行调整后再进行裁剪,并计算中位赔率以估计变异性:在 4250 例尝试进行 CTO PCI 的患者中,40% 的患者接受了≥2 种抗心绞痛药物治疗,24% 的患者接受了术前压力测试。在研究期间,CTO PCI 前接受一种以上抗心绞痛药物治疗的几率没有变化(几率比 [OR],1.0 [95% CI,0.97-1.04]),而接受术前压力测试的几率有所下降(OR,0.97 [95% CI,0.93-0.99]),接受≥2 种抗心绞痛药物治疗和压力测试的几率没有变化(OR,0.98 [95% CI,0.93-1.04])。中位几率比(MOR)显示,不同医院(MOR,1.3 [95% CI,1.26-1.42])和不同操作者(MOR,1.35 [95% CI,1.26-1.63])在抗心绞痛治疗方面存在很大差异。同样,不同医院(MOR,1.68[95% CI,1.58-1.81])和不同操作者(MOR,1.80[95% CI,1.56-2.38])的术前压力测试差异也很大:结论:仅有不到一半的患者在进行CTO PCI前接受了指南推荐的治疗,而治疗部位和操作者存在显著差异。这些研究结果表明,有机会减少CTO PCI术前管理的变异性。
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来源期刊
Circulation. Cardiovascular Quality and Outcomes
Circulation. Cardiovascular Quality and Outcomes Medicine-Cardiology and Cardiovascular Medicine
CiteScore
9.80
自引率
2.90%
发文量
357
期刊介绍: Circulation: Cardiovascular Quality and Outcomes, an American Heart Association journal, publishes articles related to improving cardiovascular health and health care. Content includes original research, reviews, and case studies relevant to clinical decision-making and healthcare policy. The online-only journal is dedicated to furthering the mission of promoting safe, effective, efficient, equitable, timely, and patient-centered care. Through its articles and contributions, the journal equips you with the knowledge you need to improve clinical care and population health, and allows you to engage in scholarly activities of consequence to the health of the public. Circulation: Cardiovascular Quality and Outcomes considers the following types of articles: Original Research Articles, Data Reports, Methods Papers, Cardiovascular Perspectives, Care Innovations, Novel Statistical Methods, Policy Briefs, Data Visualizations, and Caregiver or Patient Viewpoints.
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