美国国立心血管数据注册处最近基于对近2百万例患者和1500个实验室数据的分析结果，首次报告了有关美国诊断性插管和经皮冠状动脉介入(PCI)治疗的现状(J. Amer. Coll. Cardiol. 2012 [doi:10.1016/j.jacc.2012.08.966])。
By: NASEEM S. MILLER, Cardiology News Digital Network
The National Cardiovascular Data Registry for the first time has published a report on the state of diagnostic catheterization and percutaneous coronary intervention in the United States based on data from nearly 2 million patients and 1,500 laboratories.
The document does not show specific information on individual facilities or patients, but it provides perspective and benchmarks on various aspects of invasive cardiac procedures.
It is more of "a biopsy of where things are in invasive cardiology today," said lead author Dr. Gregory J. Dehmer.
The report is an aggregate of data collected from facilities registered with CathPCI Registry, which captures as many as 85% of the PCI procedures performed in the United States (J. Amer. Coll. Cardiol. 2012 [doi:10.1016/j.jacc.2012.08.966]).
Between January 2010 and June 2011, almost half of the registered facilities performed 400 or fewer PCI procedures annually (considered low volume), while 13% performed more than 1,000.
Only 4% of PCI procedures were performed in laboratories that performed 200 or fewer procedures per year. Nearly 90% of the facilities that were considered low volume did not have on-site cardiac surgery.
The authors pointed out that the 2011 PCI guideline recommends that low-volume operators not perform PCI procedures at low-volume facilities and that facilities performing fewer than 200 PCI procedures, "unless geographically isolated, carefully consider whether to continue to offer this service."
Forty-nine centers reported performing 10 or fewer PCI procedures annually.
Patients were broken down in two groups: nearly 1.1 million who underwent only diagnostic cardiac catheterization, and more than 940,000 patients who underwent PCI.
In both groups, almost 80% of the patients were overweight, and more than 40% were obese, possibly pointing to the fact that "America is getting fatter," said Dr. Dehmer, professor of medicine at Texas A&M Health Science Center, Bryan. Approximately 1% of the patients were considered thin.
Of those undergoing PCI, roughly 70% had a type of acute coronary syndrome, while nearly 45% of patients who underwent diagnostic procedures had an acute coronary syndrome at presentation.
Meanwhile, roughly 87% of the patients who underwent PCI had a single vessel treated. These data show that "interventional cardiologists had not used multivessel PCI excessively," said Dr. Dehmer. Also, 13% of the patients had two vessels treated, and 0.7% had three vessels treated.
The limitation to this information, however, was that the data did not pick up on patients who had a staged procedure, Dr. Dehmer pointed out.
The report also showed that U.S. interventional cardiologists still prefer the femoral route to radial or brachial access in patients undergoing PCI (93% vs. 7% vs. 0.4%, respectively) or diagnostic procedures (91% vs. 8% vs. 0.4%, respectively).
Although the United States is lagging behind Europe in using radial approach, "it’s catching on," said Dr. Dehmer, reflecting on changes in his own practice.
There has also been a lot of concern about the overuse of coronary CT angiography, said Dr. Dehmer. The analysis shows that the test was performed on less than 3% of PCI patients, and on less than 2% of those undergoing diagnostic catheterization.
The report also shed light on trends in medications prescribed. Clopidogrel, for instance, was the most frequently used thienopyridine (76%), while glycoprotein IIb/IIIa inhibitors were used in nearly 30% of PCI cases and 34% of patients who had an acute coronary syndrome.
In comparison, bivalirudin was used in almost 60% of the cases, "maintaining a strong presence," said Dr. Dehmer. Low-molecular-weight heparin was used in nearly 10% of the cases. Dr. Dehmer added that data was not captured for the recently approved ticagrelor.
Nearly all patients without contraindication were receiving aspirin and a thienopyridine at the time of discharge.
Authors noted that the CathPCI Registry is not only used to understand the practice of invasive cardiology but also to drive a higher level of quality into individual practices.
CathPCI Registry, which has been around since the late 1990s, sends quarterly reports to participating facilities.
Dr. Dehmer said that National Cardiovascular Data Registry is planning to update the public report periodically, "so that the next time we can see how things are changing."
Dr. Dehmer had no relevant disclosures.