The Changing Face of Interventional Cardiology
2012; Lippincott Williams & Wilkins; Volume: 5; Issue: 3 Linguagem: Inglês
10.1161/circinterventions.112.971671
ISSN1941-7632
AutoresDavid P. Faxon, David O. Williams,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculation: Cardiovascular InterventionsVol. 5, No. 3The Changing Face of Interventional Cardiology Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessEditorialPDF/EPUBThe Changing Face of Interventional Cardiology David P. Faxon, MD and David O. Williams, MD David P. FaxonDavid P. Faxon From the Department of Medicine, Brigham and Women's Hospital, Boston, MA. and David O. WilliamsDavid O. Williams From the Department of Medicine, Brigham and Women's Hospital, Boston, MA. Originally published1 Jun 2012https://doi.org/10.1161/CIRCINTERVENTIONS.112.971671Circulation: Cardiovascular Interventions. 2012;5:325–327Change is the only constant (derived from "all entities move and nothing remains still").—Heraclitus, 401 BCInterventional cardiology began as a discipline after the introduction of coronary balloon angioplasty by Andreas Gruentzig in 1976.1 Technological advances, improved success, and reduced complications led to widespread acceptance of this new procedure, surpassing coronary artery bypass graft (CABG) as the most common means to achieve coronary revascularization. With time, there has been an expansion of the tools used for the coronary angioplasty, and the procedure has been renamed percutaneous coronary intervention (PCI) as a result. Changes in the practice of interventional cardiology over the last 10 years have been more subtle than the first 25 years that were dominated by technological advances, but they are still significant as we gained a better understanding of the best application of PCI. This period has been more about "what we should do" rather than "what we can do." Expansion of noncoronary interventions including peripheral arterial and structural heart disease interventions has also taken place and probably will dominate the future. Some of the more important changes in practice over the last decade will be discussed with speculation on the future of interventional cardiology.Practitioners are well aware that coronary interventional volume has been decreasing over the last 6 to 8 years. A recent study by Riley et al,2 using the data available from the Centers for Medicare and Medicaid Services from 2001 to 2009, showed that in the United States, diagnostic catheterizations rose from 1 075 623 procedures in 2001 to 1 315 515 in 2004, followed by a steady decline to 1 047 945 in 2009. Similarly, PCI volume rose until 2004 and then fell to 350 134 in 2009. Despite this dip after 2004, there has been an overall average increase of 1.3% per year over this 8-year period. Remarkably, the greatest change has been a steady decline in CABG from 316 951 in 2001 to 203 025 in 2009, a 5% per year decline. Others have shown similar changes. Epstein et al,3 using the data from the Agency for Healthcare Research and Quality (AHRQ) healthcare cost and utilization project, demonstrated a 15% decline in coronary revascularizations. Studies from New York and Ontario and North Carolina are also consistent with these trends.4,5The cause of the decline in cardiac catheterization volume is multifactorial. The factors that have contributed include a decrease in the prevalence of coronary disease due to improved primary prevention and improvement in medical therapy and secondary prevention for those with established disease. The reduction in disease prevalence is demonstrated by the reduction in death due to cardiovascular disease (CVD) by 30% since it peak in 1980.6 However, we have a long way to go to truly preventing CVD, as ideal control of the 7 key risk factors was only 0.1% in a study of healthy people in the United States.7 Rates of poorly controlled CVD risk factors for patients with known disease are also unacceptably high.8 The current decline in CVD may be short-lived if the current increase in obesity by 8% to 15% and type 2 diabetes by 60% over the last 10 years persists.6 The aging of the population probably will be the most important factor for the increase in CVD in the future, with coronary heart disease expected to increase by 7.5% in the next decade and by 16% over the next 20 years.9A decline in overall revascularization volume has also contributed to the fall in cardiac catheterization procedure rates, but the fall has been greater for CABG than for PCI. The declines in surgery have been largely attributed to a shift to the use of PCI in the majority of patients needing revascularization. Currently, only patients with the most complex CAD are referred for CABG. The smaller fall in PCI volume than with CABG is also due to an increase in the numbers of patients with acute coronary syndrome treated with PCI. It is well known that the prevalence of myocardial infarction has declined by 60% since 1970.6 While the decline is evident on a population basis, there has seen a relative increase in the percentage of patients with myocardial infarction referred for PCI. This change is due to the demonstrated survival advantage of PCI for high-risk non–ST segment–myocardial infarction (NSTEMI) and ST segment–myocardial infarction (STEMI). As shown in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry, the percentage of patients with myocardial infarction undergoing PCI rose from 23% to 36% between 1998 and 2006.10 This was accompanied by a significant increase in urgent and emergent cases. Although the distribution of STEMI versus NSTEMI had been reported to be equivalent (ranging from 30% to 60%),6 recent evidence suggests a shift to more PCI procedures in NSTEMI patients than in STEMI patients. This change is probably related to an expansion of the definition of myocardial infarction with the use of sensitive troponin assays rather than creatine kinase-MB, resulting in an increase in the number of patients classified as NSTEMI. In one study from the ACCIS registry, the number of NSTEMI acute coronary syndrome patients increased by 33% between 2000 and 2002 as troponin assay use increased from 20% to 60%.11 This increase in the number of NSTEMI patients treated by PCI has been greater than the increase in the use of PCI for STEMI, even though primary PCI is the preferred treatment for STEMI in the United States.12The greatest reduction in PCI volume has been in patients with stable angina. In a study by Ahmed et al13 from the Northern New England Cardiovascular Disease study group, PCI for stable angina accounted for 20% of all PCIs in 2006 but declined by 26% by 2009. In contrast, those with PCI for other indications declined only a 10% over the same time period. This decline was temporally related to the publication of the COURAGE trial that supported a conservative medical treatment of many patients with stable angina.14 Also, the prevalence of patients with stable angina may be declining, as the threshold for identifying such patients is extraordinarily low. Finally, improved medical therapy and lower rates of restenosis due to the widespread use of drug-eluting stents have contributed. The reduction in restenosis alone has decreased repeat procedures by 40% to 60%.15 In the NHLBI Dynamic registry, the number of patients with repeat procedures (CABG or PCI) fell from 22% to 10.5% between 1998 and 2006.10 Despite the decrease in PCI for stable angina, PCI overall is projected to grow 1% per year over the next 4 years from industry sources.16In contrast, noncoronary interventions have been increasing in frequency. Data from the Nationwide Inpatient Sample of 2 148 924 hospital admissions for peripheral artery disease (20% of all US hospital admissions) showed that the choice of treatment has dramatically changed, with a 78% increase in endovascular procedures with a concomitant decrease in open bypass and amputations.17 Interventional radiologists, cardiologists, and vascular surgeons all perform endovascular procedures. The distribution of cases has shifted significantly.18 Between 1998 and 2005, there was a 6-fold drop in procedures for interventional radiologists (5.6% of all cases in 2005), a 3-fold increase for interventional cardiologists (29% of all cases), and a 2-fold increase for vascular surgeons (43% of all cases). Many but not all interventional laboratories have the capability to do peripheral vascular interventions, but the numbers are rapidly growing, with many training programs now offering additional training in these techniques. Advances in technology, uses of drug-eluting stents, and intravascular imaging have helped to increase success and reduce complications. It is estimated by industry that peripheral interventions will grow an average of 8% per year over the next 4 years.16Structural heart disease is the area of interventional cardiology most likely to realize the greatest growth in the next 10 years.19,20 The incidence of aortic and mitral valve disease is increasing, although good estimates of the prevalence of the disease are lacking. In a pooled analysis of 3 large, population-based epidemiological studies, the prevalence of aortic and mitral valve disease in the population was estimated to be 2.5% but ranged from less than 1% for those under 54 years old to 4% to 8% by age 65 to 74 and 12% to 14% over age 75.21 Based on this study, aortic and mitral valve disease should significantly increase in prevalence in the future due to aging of the population.The development of transcatheter aortic valve replacement has changed the interventional landscape. After approval of the Edwards valve in 2007 and the CoreValve shortly thereafter in Europe, TAVR has grown to more than 60 000 procedures outside of the United States in 2011.16 In the United States, the Edwards valve was approved in 2011 after the dramatic results of the PARTNERS trial, and the CoreValve is expected to be approved next year after conclusion of the pivotal US trial. It is expected that as these valves become available that TAVR will grow from its current 2000 per year to 25 000 per year in the United States by 2015.16 Further advances with better delivery systems, lower profiles, and alternative valve designs will cause even more growth. Randomized trials are underway to determine if the technique is comparable to surgical valve replacement in intermediate-risk patients (PARTNERS 2 and SURTAVI), and, if this is shown to be true, even further increases in volume are expected. Application to aortic insufficiency and mitral and tricuspid valve disease has already been shown possible, but specific devices must be developed. All structural heart disease interventional techniques are expected to grow by 30% over the next decade.16The practice of interventional cardiology will undoubtedly be different in the next decade. Coronary intervention will remain the dominant procedure for the interventionalist, and the number of procedures will grow slowly as the population ages. The increase in peripheral interventions probably will be greater than for coronary, but the greatest and most profound change will be in the growth of valvular heart disease interventions. New technology and improved imaging will be necessary and likely. The interventional laboratory of the future will be a different one from today, and the interventionist of the future will need to be skilled in many more techniques than just coronary interventions. Training programs will need to rapidly adapt to these changes, and many are already doing so. Everything does change—and in the case of interventional cardiology—for the better.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the American Heart Association.Correspondence to David P. 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Fuchs F, Grube E and Nickenig G (2015) Tratamento percutâneo combinado de defeitos cardíacos estruturais e congênitos: mais do que apenas um procedimento viável no laboratório de cateterismo, Revista Brasileira de Cardiologia Invasiva, 10.1016/j.rbci.2015.06.001, 23:1, (6-7), Online publication date: 1-Jan-2015. Bass T (2014) Interventional Cardiology US Workforce, Circulation: Cardiovascular Interventions, 7:6, (733-735), Online publication date: 1-Dec-2014.Bass T (2012) Certification and Competency in Interventional Cardiology, Circulation: Cardiovascular Interventions, 5:4, (450-453), Online publication date: 1-Aug-2012. June 2012Vol 5, Issue 3 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.112.971671PMID: 22715447 Originally publishedJune 1, 2012 Keywordsinterventional cardiologyPDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsStent
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