Trends and Outcomes for Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in New South Wales from 2008 to 2019
2022; Elsevier BV; Volume: 187; Linguagem: Inglês
10.1016/j.amjcard.2022.10.047
ISSN1879-1913
AutoresMd Shajedur Rahman Shawon, Michael O. Falster, Benjumin Hsu, Jennifer Yu, Sze‐Yuan Ooi, Louisa Jorm,
Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoRisk profiles are changing for patients who undergo percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). In Australia, little is known of the nature of these changes in contemporary practice and of the impact on patient outcomes. We identified all CABG (n = 40,805) and PCI (n = 142,399) procedures in patients aged ≥18 years in New South Wales, Australia, during 2008 to 2019. Between 2008 and 2019, the age- and gender-standardized revascularization rate increased by 20% (from 267/100,000 to 320/100,000 population) for all revascularizations. The increase in revascularization was particularly driven by a 35% increase (from 194/100,000 to 261/100,000) in PCI, whereas the rate of CABG decreased by 20% (from 73/100,000 to 59/100,000). Mean age and the prevalence of co-morbidities (especially diabetes and atrial fibrillation) increased for patients with PCI in more recent years but remained consistently lower than for patients with CABG. CABGs performed in patients presenting with a non–ST-segment-elevation acute coronary syndrome halved from 34.3% to 18.7% during the study period, whereas PCIs in this group decreased from 36.5% to 29.6%. Risk-adjusted in-hospital mortality decreased by 7.5 deaths/1,000 procedures per month for CABG but remained unchanged for PCI. Risk-adjusted readmission rates were consistently higher for CABG than for PCI and did not change significantly over time. In conclusion, we observed a dramatic shift over time from CABG to PCI as the revascularization procedure of choice, with the patient base for PCI extending to older and sicker patients. There was a large decrease in mortality after CABG, whereas mortality after PCI remained unchanged. Risk profiles are changing for patients who undergo percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). In Australia, little is known of the nature of these changes in contemporary practice and of the impact on patient outcomes. We identified all CABG (n = 40,805) and PCI (n = 142,399) procedures in patients aged ≥18 years in New South Wales, Australia, during 2008 to 2019. Between 2008 and 2019, the age- and gender-standardized revascularization rate increased by 20% (from 267/100,000 to 320/100,000 population) for all revascularizations. The increase in revascularization was particularly driven by a 35% increase (from 194/100,000 to 261/100,000) in PCI, whereas the rate of CABG decreased by 20% (from 73/100,000 to 59/100,000). Mean age and the prevalence of co-morbidities (especially diabetes and atrial fibrillation) increased for patients with PCI in more recent years but remained consistently lower than for patients with CABG. CABGs performed in patients presenting with a non–ST-segment-elevation acute coronary syndrome halved from 34.3% to 18.7% during the study period, whereas PCIs in this group decreased from 36.5% to 29.6%. Risk-adjusted in-hospital mortality decreased by 7.5 deaths/1,000 procedures per month for CABG but remained unchanged for PCI. Risk-adjusted readmission rates were consistently higher for CABG than for PCI and did not change significantly over time. In conclusion, we observed a dramatic shift over time from CABG to PCI as the revascularization procedure of choice, with the patient base for PCI extending to older and sicker patients. There was a large decrease in mortality after CABG, whereas mortality after PCI remained unchanged. The landscape of coronary revascularization, including coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) for patients with coronary artery disease (CAD), has changed dramatically over the past 20 years.1Lahoud R Dauerman HL. Fall and rise of coronary intervention.J Am Heart Assoc. 2020; 9e016853Crossref PubMed Scopus (6) Google Scholar Studies from the United States,2Alkhouli M Alqahtani F Kalra A Gafoor S Alhajji M Alreshidan M Holmes DR Lerman A. Trends in characteristics and outcomes of patients undergoing coronary revascularization in the United States, 2003–2016.JAMA Netw Open. 2020; 3e1921326Crossref Scopus (91) Google Scholar, 3California Society of Thoracoc Surgeons. California Cardiac Surgery Intervention Project. Available at: https://www.californiacardiacsurgery.com/CCSIP2011/procedures.html. Accessed on 02 May 2022.Google Scholar, 4Kataruka A Maynard CC Kearney KE Mahmoud A Bell S Doll JA McCabe JM Bryson C Gurm HS Jneid H Virani SS Lehr E Ring ME Hira RS Temporal trends in percutaneous coronary Intervention and coronary artery bypass grafting: insights From the Washington cardiac care outcomes assessment program.J Am Heart Assoc. 2020; 9e015317Crossref PubMed Scopus (26) Google Scholar, 5Ko W Tranbaugh R Marmur JD Supino PG Borer JS. Myocardial revascularization in New York State: variations in the PCI-to-CABG ratio and their implications.J Am Heart Assoc. 2012; 1e001446Crossref PubMed Google Scholar, 6Raza S Deo SV Kalra A Zia A Altarabsheh SE Deo VS Mustafa RR Younes A Rao SV Markowitz AH Park SJ Costa MA Simon DI Bhatt DL Sabik III, JF Stability After initial decline in coronary revascularization rates in the United States.Ann Thorac Surg. 2019; 108: 1404-1408Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 7Patlolla SH Kanwar A Cheungpasitporn W Doshi RP Stulak JM Holmes DR Bell MR Singh M Vallabhajosyula S. Temporal trends, clinical characteristics, and outcomes of emergent coronary artery bypass grafting for acute myocardial infarction in the United States.J Am Heart Assoc. 2021; 10e020517Crossref Scopus (5) Google Scholar the United Kingdom,8Grant SW Kendall S Goodwin AT Cooper G Trivedi U Page R Jenkins DP. Trends and outcomes for cardiac surgery in the United Kingdom from 2002–2016.JTCVS Open. 2021; 7: 259-269Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar and Israel9Blumenfeld O Na'amnih W Shapira-Daniels A Lotan C Shohat T Shapira OM Trends in coronary revascularization and ischemic heart disease-Related mortality in Israel.J Am Heart Assoc. 2017; 6e004734Crossref PubMed Scopus (24) Google Scholar have reported decreasing population rates of index coronary revascularization. Because of concurrent innovations in PCI technologies, patients at higher risk (i.e., older and with several co-morbidities) with increasingly complex coronary lesions are who underwent PCI instead of CABG in recent years.5Ko W Tranbaugh R Marmur JD Supino PG Borer JS. Myocardial revascularization in New York State: variations in the PCI-to-CABG ratio and their implications.J Am Heart Assoc. 2012; 1e001446Crossref PubMed Google Scholar,9Blumenfeld O Na'amnih W Shapira-Daniels A Lotan C Shohat T Shapira OM Trends in coronary revascularization and ischemic heart disease-Related mortality in Israel.J Am Heart Assoc. 2017; 6e004734Crossref PubMed Scopus (24) Google Scholar,10Carnero Alcazar M Hernandez-Vaquero D Cubero-Gallego H Lopez Menendez J Piñon M Albors Martin J Cuerpo Caballero G Cobiella Carnicer J Villamor C Forteza A Pascual I Maroto Castellanos LC Retrospective cohort analysis of Spanish national trends of coronary artery bypass grafting and percutaneous coronary intervention from 1998 to 2017.BMJ Open. 2021; 11e046141Crossref PubMed Scopus (4) Google Scholar These shifts in procedure choice and patient risk profile are likely to affect patient outcomes after these procedures.2Alkhouli M Alqahtani F Kalra A Gafoor S Alhajji M Alreshidan M Holmes DR Lerman A. Trends in characteristics and outcomes of patients undergoing coronary revascularization in the United States, 2003–2016.JAMA Netw Open. 2020; 3e1921326Crossref Scopus (91) Google Scholar,4Kataruka A Maynard CC Kearney KE Mahmoud A Bell S Doll JA McCabe JM Bryson C Gurm HS Jneid H Virani SS Lehr E Ring ME Hira RS Temporal trends in percutaneous coronary Intervention and coronary artery bypass grafting: insights From the Washington cardiac care outcomes assessment program.J Am Heart Assoc. 2020; 9e015317Crossref PubMed Scopus (26) Google Scholar, 5Ko W Tranbaugh R Marmur JD Supino PG Borer JS. Myocardial revascularization in New York State: variations in the PCI-to-CABG ratio and their implications.J Am Heart Assoc. 2012; 1e001446Crossref PubMed Google Scholar, 6Raza S Deo SV Kalra A Zia A Altarabsheh SE Deo VS Mustafa RR Younes A Rao SV Markowitz AH Park SJ Costa MA Simon DI Bhatt DL Sabik III, JF Stability After initial decline in coronary revascularization rates in the United States.Ann Thorac Surg. 2019; 108: 1404-1408Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 7Patlolla SH Kanwar A Cheungpasitporn W Doshi RP Stulak JM Holmes DR Bell MR Singh M Vallabhajosyula S. Temporal trends, clinical characteristics, and outcomes of emergent coronary artery bypass grafting for acute myocardial infarction in the United States.J Am Heart Assoc. 2021; 10e020517Crossref Scopus (5) Google Scholar, 8Grant SW Kendall S Goodwin AT Cooper G Trivedi U Page R Jenkins DP. Trends and outcomes for cardiac surgery in the United Kingdom from 2002–2016.JTCVS Open. 2021; 7: 259-269Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 9Blumenfeld O Na'amnih W Shapira-Daniels A Lotan C Shohat T Shapira OM Trends in coronary revascularization and ischemic heart disease-Related mortality in Israel.J Am Heart Assoc. 2017; 6e004734Crossref PubMed Scopus (24) Google Scholar, 10Carnero Alcazar M Hernandez-Vaquero D Cubero-Gallego H Lopez Menendez J Piñon M Albors Martin J Cuerpo Caballero G Cobiella Carnicer J Villamor C Forteza A Pascual I Maroto Castellanos LC Retrospective cohort analysis of Spanish national trends of coronary artery bypass grafting and percutaneous coronary intervention from 1998 to 2017.BMJ Open. 2021; 11e046141Crossref PubMed Scopus (4) Google Scholar, 11Culler SD Kugelmass AD Brown PP Reynolds MR Simon AW. Trends in coronary revascularization procedures among Medicare beneficiaries between 2008 and 2012.Circulation. 2015; 131: 362-370Crossref PubMed Scopus (70) Google Scholar Therefore, ongoing monitoring of rates of CABG and PCI and of outcomes is crucial for our understanding of trends shaping the care of patients with CAD. However, reports on temporal trends in revascularization in Australia do not reflect contemporary practice and outcomes.12Weerasinghe DP Wolfenden HD Yusuf F. Coronary artery bypass graft surgery trends in New South Wales, Australia.Public Health. 2008; 122: 151-160Crossref PubMed Scopus (5) Google Scholar, 13Yan BP Ajani AE Clark DJ Duffy SJ Andrianopoulos N Brennan AL Loane P Reid CM. Recent trends in Australian percutaneous coronary intervention practice: insights from the Melbourne Interventional Group registry.Med J Aust. 2011; 195: 122-127Crossref PubMed Scopus (17) Google Scholar, 14Dinh DT Lee GA Billah B Smith JA Shardey GC Reid CM. Trends in coronary artery bypass graft surgery in Victoria, 2001–2006: findings from the Australasian Society of Cardiac and Thoracic Surgeons database project.Med J Aust. 2008; 188: 214-217Crossref PubMed Scopus (57) Google Scholar, 15Brieger DB Ng ACC Chow V D'Souza M Hyun K Bannon PG Kritharides L Falling hospital and postdischarge mortality following CABG in New South Wales from 2000 to 2013.Open Heart. 2019; 6e000959Crossref PubMed Scopus (8) Google Scholar Using whole-of-population data for patients who underwent CABG and PCI between 2008 and 2019 in New South Wales (NSW), Australia's largest state, we aimed to (1) quantify population rates and temporal trends for revascularization procedures; (2) identify changes in patient risk profiles and procedural characteristics; and (3) estimate trends in risk-adjusted rates for mortality and readmission after revascularization procedures. We used linked data from the NSW Admitted Patient Data Collection (APDC) and NSW Registry of Births, Deaths, and Marriage mortality data file. The APDC contains information on separations (admissions, transfers, and deaths) from all public and private hospitals in NSW. The APDC collects a standard set of patient demographic characteristics, primary and secondary (up to 50) diagnoses, and primary and secondary (up to 50) procedures performed. Diagnoses are coded according to the Australian modification of the International Statistical Classification of Diseases (ICD) and Related Problems 10th Revision (ICD-10-AM), and procedures are coded according to the Australian Classification of Health Interventions. Data linkage was performed probabilistically by the NSW Centre for Health Record Linkage (https://www.cherel.org.au/), with an estimated false-positive rate of 5/1,000 (0.5%).16Boyd JH Randall SM Ferrante AM Bauer JK McInneny K Brown AP Spilsbury K Gillies M Semmens JB. Accuracy and completeness of patient pathways – the benefits of national data linkage in Australia.BMC Health Serv Res. 2015; 15: 312Crossref PubMed Scopus (24) Google Scholar We identified all CABG and PCI procedures performed in adult patients (aged 18 years or more) between January 1, 2008 and December 31, 2019 from the NSW APDC, using the Australian Classification of Health Interventions codes in the primary and all secondary procedure fields. We also created a separate study dataset that included only “new” or “index” revascularization procedures. On the basis of findings regarding appropriate clearance periods of a previous Australian study using linked administrative data,17Katzenellenbogen JM Somerford P Semmens JB Codde JP. Effect of clearance periods on hospital stroke incidence using linked administrative data.Int J Stroke. 2010; 5: 336-337Crossref PubMed Scopus (8) Google Scholar we defined index procedures as those performed in patients who had no records of revascularization irrespective of the type (i.e., CABG or PCI) in the previous 5 years. In addition, to identify the influence of the duration of the clearance period, we performed a sensitivity analysis using data for the years 2012 to 2019 with a 10-year clearance period. We excluded patients if they had inconsistent admission, discharge, or death dates indicating potential data linkage errors. We treated transfers between hospitals and changes in types of care (e.g., from acute to subacute) as a continuation of the same period of hospital stay. We evaluated 2 mortality outcomes: in-hospital mortality (death from any cause during hospital stay) and 30-day mortality (death from any cause within 30 days of the date of the revascularization procedure). We also assessed 30-day readmission, representing any emergency hospitalization within 30 days of discharge. The emergency status of the hospitalization was coded on the basis of the opinion of the treating clinician on whether care or treatment was required within 24 hours. To allow comparison with international benchmarks (i.e., the approach used by the Centers for Medicare & Medicaid Services in assessing hospital mortality and readmission),18Khera R Dharmarajan K Wang Y Lin Z Bernheim SM Wang Y Normand SLT Krumholz HM. Association of the hospital readmissions reduction program With mortality During and After hospitalization for acute myocardial infarction, heart failure, and pneumonia.JAMA Netw Open. 2018; 1e182777Crossref PubMed Scopus (71) Google Scholar we also excluded those who left hospital against medical advice from analyses related to outcomes of revascularization procedures. We stratified patient cohorts with CABG and PCI according to calendar year (from January 1 to December 31) based on the procedure date. For each calendar year, we then calculated age- and gender-standardized rates per 100,000 population for total revascularization, CABG, and PCI by direct standardization using the 2011 NSW mid-year population estimates from the Australian Bureau of Statistics as the standard population.19Australian Bureau of Statistics. Regional population growth, Australia 2010-11. Available at:https://www.abs.gov.au/ausstats/[email protected]/Products/3218.0∼2010-11∼Main±Features∼Main±Features?OpenDocument#:∼:text=3218.0%20%2D%20Regional%20Population%20Growth%2C%20Australia%2C%202010%2D11&text=Australia's%20estimated%20resident%20population%20(ERP,people%20since%2030%20June%202010. Accessed on XXX.Google Scholar We also calculated the yearly PCI-to-CABG ratio by dividing the total number of PCI procedures performed in a year by the total number of CABG procedures performed per year. We reported yearly patterns and trends in patient characteristics (age at procedure, gender, presence of various co-morbidities) and procedural characteristics (emergency admission, hospital type, clinical presentation, length of stay, and procedure type). We identified the presence of co-morbidities from primary and additional diagnosis fields recorded for the hospitalization with the revascularization procedure or any hospitalization up to 5 years previously. Clinical presentations for the revascularization procedures were ascertained using ICD-10-AM codes from primary and secondary diagnosis fields. We grouped the clinical presentations into ST-segment elevation myocardial infarction (STEMI) (ICD codes I21.0 to I21.3), non–ST-segment elevation acute coronary syndrome (NSTEACS) (ICD codes I21.4 for non–ST-segment elevation myocardial infarction and I20.0 for unstable angina), and stable ischemic heart disease (SIHD) (ICD code I25).20Nedkoff L Lopez D Goldacre M Sanfilippo F Hobbs M Wright FL. Identification of myocardial infarction type from electronic hospital data in England and Australia: a comparative data linkage study.BMJ Open. 2017; 7e019217Crossref Scopus (10) Google Scholar Descriptive characteristics were summarized as frequencies and percentages for categorical variables, and continuous variables were presented either as mean (SD) or as median (interquartile range). To test trends in characteristics by year, we used the Mantel-Haenszel test for trend for categorical variables and linear regression for continuous variables. To assess temporal trends in mortality and readmission outcomes while accounting for potential changes in patients’ risk profile over time, we constructed multiple logistic regression models with mortality or readmission as the dependent variable and patient characteristics (age, gender, and various co-morbidities) as independent variables. From these regression models, we estimated risk-adjusted rates for each outcome for each of the 144 calendar months during the study period (January 2008 to December 2019). The monthly risk-adjusted rates were obtained using indirect standardization, defined as the ratio of the observed rate of the outcome to the expected rate of the respective outcome in the risk-adjustment model above, multiplied by the unadjusted rate of the outcome observed during the 12-year study period. Temporal changes in risk-standardized rates of the outcomes across months were then examined using linear regression models. We interpreted the slopes from regression lines as the average change in mortality and readmission rates per 1,000 procedures over a month in the study period. We additionally stratified temporal trends in risk-adjusted mortality and readmission outcomes by characteristics of the procedure and clinical presentation. This study was granted ethical approval by the University of New South Wales, NSW Population and Health Services Research (HREC/18/CIPHS/56), Aboriginal Health and Medical Research Council of NSW (1503/19), and Australian Institute of Health and Welfare (EO2018/2/431) research ethics committees. We reported all data in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.21von Elm E Altman DG Egger M Pocock SJ Gøtzsche PC Vandenbroucke JP Initiative STROBE Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.BMJ. 2007; 335: 806-808Crossref PubMed Google Scholar All analyses were conducted using Stata version 16.0 (College Station, Texas). The p <0.05 were considered statistically significant. We included 40,805 hospitalizations with a CABG procedure and 142,399 hospitalizations with a PCI procedure for calculation of rates of procedures. The outcome analysis was based on 40,672 CABG and 141,719 PCI procedures (Supplementary Figures 1 and 2). Figure 1 shows the trends in age- and gender-standardized rates for total revascularization, CABG, and PCI between 2008 and 2019. Overall, the rate of total revascularization increased by 20% during the study period (from 267/100,000 to 320/100,000 population), particularly driven by a large increase (∼35%) in PCI rates (from 194/100,000 to 261/100,000 population). The annual CABG rate, however, decreased steadily from 73/100,000 population in 2008 to 59/100,000 in 2019 (an overall 20% decrease). These diverging trends in population rates led the PCI:CABG ratio to increase from 2.7 in 2008 to 4.4 in 2019 (Figure 1). When we looked at index procedures only, we found that the annual standardized rate for revascularization increased by 16% (from 202/100,000 to 234/100,000 population) during the study period (Figure 1). The rate of PCI as the index revascularization increased by 32% (from 137/100,000 to 181/100,000 population) between 2008 and 2019, whereas the rate of CABG as an index procedure decreased by 20% (from 66/100,000 to 53/100,000 population) during the same period. Similar trends were observed when we restricted our data from 2012 to 2019 with a 10-year clearance period to identify index procedures (Supplementary Table 1). Gender-based differences in the revascularization trends are shown in Supplementary Tables 2 and 3. Table 1 shows selected patient and procedural characteristics of revascularization procedures in periods of 3 years. Overall, the mean age at revascularization procedure increased from 67.3 years (SD 11.6) in 2008 to 2010 to 68.8 years (SD 11.5) in 2017 to 2019. The mean age at PCI increased from 66.8 years (SD 12.0) in 2008 to 2010 to 69.0 years (SD 11.8) in 2017 to 2019, whereas the mean age at CABG remained stable over the years at approximately 68 years. Approximately 1 in 4 revascularization procedures during the study period was performed in women. The proportion of female patients decreased from 26.6% to 25.1% for PCI over the study period and from 22.6% to 18.7% for CABG. The clinical characteristics and presentations of revascularization procedures also changed significantly over time (Table 1). Compared with earlier periods, the proportion of coronary revascularizations performed within an emergency admission increased in recent periods, but the proportion of index procedure decreased. The median length of stay increased significantly over the years for CABG but remained steady for PCI. The proportion of revascularization procedures performed for SIHD increased from 57.7% to 76.6% for all CABG and from 42.2% to 50.0% for all PCI. The proportion of revascularization procedures performed for NSTEACS decreased significantly over time, with a greater decrease for CABG (from 34.3% to 18.7%) than for PCI (from 36.5% to 29.6%). Although the proportions of CABG performed for STEMI decreased from 6.7% to 3.7%, the proportions of PCI performed for STEMI remained steady over the years at approximately 18%. Over the years, 4 of 5 CABG cases were isolated CABG, whereas a smaller proportion of patients who underwent CABG in 2017 to 2019 than of those who underwent CABG in 2008 to 2010 had ≥2 grafts (16.9% vs 13.2%). We observed increasing trends in the proportions of patients with PCI with multistent or multivessel procedures (Table 1). Analysis of index revascularization procedures yielded similar trends for clinical characteristics and presentations (Supplementary Table 4). The prevalence of various medical co-morbidities in patients who underwent revascularization increased over time, particularly for those who underwent PCI (Table 2).Table 1Selected characteristics for all revascularization, CABG, and PCI procedures, by yearCharacteristics2008-102011-132014-162017-19P-value*Mantel-Haenszel test for trend was used for categorical variables, and linear regression was used for continuous variables.All revascularizationNo. of procedures43056436524656149931Age in years, mean (SD)67.3 (11.6)67.8 (11.7)68.2 (11.6)68.8 (11.5)<0.001Female11027 (25.6)10880 (24.9)11191 (24.0)11919 (23.9)<0.001LOS in days, median (IQR)5 (2,10)4 (1,10)4 (1,10)4 (1,9)<0.001Private hospital18143 (42.1)18706 (42.9)20651 (44.4)20905 (41.9)0.916Emergency admission13654 (31.7)14709 (33.7)16495 (35.4)18838 (37.7)<0.001Index procedure†Calculated by looking into hospitalization in the preceding 5 years.32396 (75.2)32732 (75.0)35010 (75.2)36747 (73.6)<0.001Prior PCI†Calculated by looking into hospitalization in the preceding 5 years.9962 (23.1)10361 (23.7)11017 (23.7)12510 (25.1)<0.001Prior CABG†Calculated by looking into hospitalization in the preceding 5 years.888 (2.1)926 (2.1)962 (2.1)1100 (2.2)0.187Clinical presentation STEMI6787 (15.8)6862 (15.7)7584 (16.3)7899 (15.8)0.267 NSTEACS15465 (35.9)14400 (33.0)14204 (30.5)13725 (27.5)<0.001 SIHD19826.0 (46.0)21647.0 (49.6)24043.0 (51.6)27527.0 (55.1)<0.001CABGNo. of procedures1081910123102199644Age in years, mean (SD)68.5 (10.4)68.7 (10.3)68.2 (10.2)68.2 (10.0)0.001Female2448 (22.6)2144 (21.2)1977 (19.3)1802 (18.7)<0.001LOS in days, median (IQR)14 (9,22)15 (9,23)15 (10,23)15 (10,24)<0.001Private hospital4555 (42.1)4217 (41.7)4492 (44.0)4162 (43.2)0.009Emergency admission2107 (19.5)2175 (21.5)2334 (22.8)2359 (24.5)<0.001Index procedure†Calculated by looking into hospitalization in the preceding 5 years.9684 (89.5)8986 (88.8)9127 (89.3)8614 (89.3)0.901Prior PCI†Calculated by looking into hospitalization in the preceding 5 years.1087 (10.0)1097 (10.8)1065 (10.4)994 (10.3)0.726Prior CABG†Calculated by looking into hospitalization in the preceding 5 years.57 (0.5)54 (0.5)39 (0.4)42 (0.4)0.213Clinical presentation STEMI722 (6.7)540 (5.3)510 (5.0)356 (3.7)<0.001 NSTEACS3711.0 (34.3)3204.0 (31.7)2874.0 (28.1)1801.0 (18.7)<0.001 SIHD6238 (57.7)6228 (61.5)6704 (65.6)7386 (76.6)<0.001Isolated CABG8856 (81.9)8119 (80.2)8336 (81.6)7983 (82.8)0.025CABG with 2+ grafts7102 (65.6)6461 (63.8)6532 (63.9)5761 (59.7)<0.001PCINo. of procedures32237335293634240287Age in years, mean (SD)66.8 (12.0)67.6 (12.0)68.1 (11.9)69.0 (11.8)<0.001Female8579 (26.6)8736 (26.1)9214 (25.4)10117 (25.1)<0.001LOS in days, median (IQR)3 (1,6)3 (1,5)3 (1,5)3 (1,5)0.975Private hospital13588 (42.2)14489 (43.2)16159 (44.5)16743 (41.6)0.122Emergency admission11547 (35.8)12534 (37.4)14161 (39.0)16479 (40.9)<0.001Index procedure†Calculated by looking into hospitalization in the preceding 5 years.22712 (70.5)23746 (70.8)25883 (71.2)28133 (69.8)0.142Prior PCI†Calculated by looking into hospitalization in the preceding 5 years.8875 (27.5)9264 (27.6)9952 (27.4)11516 (28.6)0.005Prior CABG†Calculated by looking into hospitalization in the preceding 5 years.831 (2.6)872 (2.6)923 (2.5)1058 (2.6)0.839Clinical presentation STEMI6065 (18.8)6322 (18.9)7074 (19.5)7543 (18.7)0.730 NSTEACS11754 (36.5)11196 (33.4)11330 (31.2)11924 (29.6)<0.001 SIHD13588 (42.2)15419 (46.0)17339 (47.7)20141 (50.0)<0.001Multistent PCI10274 (31.9)9549 (28.5)11488 (31.6)13574 (33.7)<0.001Multivessel PCI4769 (14.8)4258 (12.7)5431 (14.9)6770 (16.8)<0.001Values are presented as n (%) unless otherwise mentionedIQR = interquartile range; LOS = length of stay; NSTEACS = non-ST-segment elevation acute coronary syndrome; SD = standard deviation; SIHD = stable ischemic heart disease; STEMI = ST-segment elevation myocardial infarction. Mantel-Haenszel test for trend was used for categorical variables, and linear regression was used for continuous variables.† Calculated by looking into hospitalization in the preceding 5 years. Open table in a new tab Table 2Co-morbidities among patients with revascularization, CABG, and PCI, by yearCo-morbidities2008-102011-132014-162017-19P-value*Co-morbidities were measured looking into hospitalizations with revascularization and any hospitalizations in previous 5 years.All revascularization No. of procedures43056436524656149931 Diabetes10716 (24.9)10695 (24.5)14915 (32.0)16773 (33.6)<0.001 Congestive heart failure4910 (11.4)5316 (12.2)5815 (12.5)6391 (12.8)<0.001 Atrial fibrillation12499 (29.0)13758 (31.5)16347 (35.1)18078 (36.2)<0.001 Valvular disease4410 (10.2)4432 (10.2)4646 (10.0)4646 (9.3)<0.001 Cardiogenic shock574 (1.3)731 (1.7)1007 (2.2)1132 (2.3)<0.001 Peripheral vascular disease3937 (9.1)3471 (8.0)3536 (7.6)3417 (6.8)<0.001 Pulmonary vascular disease1134 (2.6)1227 (2.8)1332 (2.9)1292 (2.6)0.886 Chronic pulmonary disease2335 (5.4)2057 (4.7)2339 (5.0)2736 (5.5)0.237 Renal failure3424 (8.0)3846 (8.8)4646 (10.0)4472 (9.0)<0.001 Liver disease441 (1.0)460 (1.1)838 (1.8)1014 (2.0)<0.001 Solid tumor, no metastasis2073 (4.8)2204 (5.0)2510 (5.4)2721 (5.4)<0.001 Metastatic cancer370 (0.9)392 (0.9)411 (0.9)547 (1.1)<0.001CABG No. of procedures1081910123102199644 Diabetes3426 (31.7)3401 (33.6)3983 (39.0)3953 (41.0)<0.001 Congestive heart failure1853 (17.1)1828 (18.1)1762 (17.2)1556 (16.1)0.023 Atrial fibrillation5553 (51.3)5687 (56.2)6212 (60.8)6012 (62.3)<0.001 Valvular disease2698 (24.9)2660 (26.3)2522 (24.7)2189 (22.7)<0.001 Cardiogenic shock212 (2.0)224 (2.2)315 (3.1)306 (3.2)<0.001 Peripheral vascular disease1441 (13.3)1165 (11.5)1081 (10.6)928 (9.6)<0.001 Pulmonary vascular disease447 (4.1)457 (4.5)432 (4.2)332 (3.4)0.020 Chronic pulmonary disease758 (7.0)656 (6.5)681 (6.7)597 (6.2)0.011 Renal failure1297 (12.0)1353 (13.4)1488 (14.6)1118 (11.6)0.705 Liver disease129 (1.2)139 (1.4)283 (2.8)272 (2.8)<0.001 Solid tumor, no metastasis584 (5.4)575 (5.7)579 (5.7)577 (6.0)0.182 Metastatic cancer79 (0.7)79 (0.8)81 (0.8)82 (0.9)0.484PCI No. of procedures32237335293634240287 Diabetes7290 (22.6)7294 (21.8)10932 (30.1)12820 (31.8)<0.001 Congestive heart failure3057 (9.5)3488 (10.4)4053 (11.2)4835 (12.0)<0.001 Atri
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