美国心脏介入治疗现状报告发布

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])。

该报告汇总了在CathPCI注册的机构所报告的数据，涵盖在美国进行的多达85%的PCI手术。

2010年1月~2011年6月，约半数注册机构每年进行的PCI手术例数≤400例，13%的注册机构每年进行的PCI手术例数超过1000例。仅有4%的PCI手术是在年手术量≤200例的机构进行的。90%手术量低的机构未开展现场心脏手术。49个中心每年进行的PCI手术例数≤10例。作者指出，2011年PCI指南建议低手术量的外科医生不应在低手术量机构进行PCI手术，此外，除非地理位置偏远，否则PCI手术量低于200例的机构应谨慎考虑是否继续提供这种服务。

110万例患者仅接受诊断性心脏插管，超过940,000例接受PCI。在这两组中，80%的患者超重，40%以上的患者肥胖，可能反映出肥胖在美国日趋流行。1%的患者被认为体瘦。就诊时，在接受PCI的患者中，70%患有急性冠脉综合征，而在接受诊断性插管的患者中，45%患有急性冠脉综合征。

在接受PCI的患者中，87%接受单支血管治疗，表明心脏介入医生未过度开展多支血管PCI。13%的患者接受双支血管治疗，0.7%接受三支血管治疗。然而，该报告的局限性在于未纳入进行分期手术的患者数据。

该报告还显示，相对于桡动脉和肱动脉入路，美国心脏介入医生仍然更喜欢采用股动脉入路。在PCI手术患者中，股动脉、桡动脉和肱动脉入路的使用率分别为93%、7%和0.4%；在诊断性插管中，三者的使用率分别为91%、8%和0.4%。冠脉CT血管造影在PCI患者中的使用率低于3%，在诊断性插管患者中的使用率低于2%。

该报告还显示了药物的使用趋势。氯吡格雷是最常用的噻吩吡啶类药物(76%)，而糖蛋白Ⅱb/Ⅲa抑制剂在PCI患者中的使用率为30%，在急性冠脉综合征患者中的使用率为34%。相比之下，比伐卢定的使用率为60%。低分子量肝素的使用率为10%。作者表示，该报告未纳入近期获批的替卡格雷的数据。几乎所有无禁忌证的患者在出院时均正在接受阿司匹林和噻吩吡啶类药物治疗。

作者声明无经济利益冲突。

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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.