TY - JOUR
T1 - Predictors and variability of drug-eluting vs bare-metal stent selection in contemporary percutaneous coronary intervention
T2 - Insights from the PRISM study
AU - Shafiq, Ali
AU - Gosch, Kensey
AU - Amin, Amit P.
AU - Ting, Henry H.
AU - Spertus, John A.
AU - Salisbury, Adam C.
N1 - Funding Information:
AS reports no relevant disclosures. ACS has received grant funding from Boston Scientific and honoraria or speaking fees from Abiomed and Medtronic. The authors declare no other potential conflicts of interest. We observed that most predictors of stent selection at the time of PCI reflect attempts to balance the benefits of lower restenosis with DES against risks of prolonged DAPT. Markers of elevated bleeding risk, such as lower Hb, prior bleeding, chronic warfarin use, and AF, as well as planned surgery, were associated with greater use of BMS, whereas DM, health insurance, white race, ST, and multivessel coronary disease were associated with greater likelihood of DES implantation. However, the substantial residual variation in DES selection after accounting for these factors underscores the importance of future studies to determine the impact of patient and provider preferences on stent selection and to further study the impact of individualized bleeding and restenosis risk prediction on decision-making at the time of PCI. AS reports no relevant disclosures. ACS has received grant funding from Boston Scientific and honoraria or speaking fees from Abiomed and Medtronic. The authors declare no other potential conflicts of interest.
Publisher Copyright:
© 2017 Wiley Periodicals, Inc.
PY - 2017/8
Y1 - 2017/8
N2 - Drug-eluting stents (DES) reduce risk of in-stent restenosis after percutaneous coronary intervention (PCI) but require dual antiplatelet therapy (DAPT) for a longer term than bare-metal stents (BMS). Few studies have examined clinical predictors of DES vs BMS, and variability in provider selection between DES and BMS in clinical practice has not been well described. These insights can inform our understanding of current practice and may identify opportunities to improve decision-making stent selection decinsion-making. In a multicenter registry, 3295 consecutive patients underwent PCI by 158 interventional cardiologists across 10 US sites. Eighty percent of patients with treated with DES. Using hierarchical regression, diabetes mellitus, multivessel disease, health insurance, and white race were independently associated with greater DES use, whereas increasing age, history of hypertension, anticipated surgery, use of warfarin, lower hemoglobin, prior history of bleeding, and treatment of right coronary and left circumflex artery lesions as compared with PCI of left anterior descending artery were associated with lower likelihood of receiving DES. Adjusted rates of DES use across providers varied from 52.3% to 94.6%, and adjusted median odds ratio for DES selection was 1.69. DES selection appeared to reflect physicians’ attempts to balance benefits of DES against risks of prolonged DAPT. Nevertheless, marked residual variability in DES selection across providers persisted after adjusting for predictors of restenosis, bleeding, and other factors. Further studies are needed to better understand drivers of this variability and identify the impact of patient and provider preferences on stent selection at the time of PCI.
AB - Drug-eluting stents (DES) reduce risk of in-stent restenosis after percutaneous coronary intervention (PCI) but require dual antiplatelet therapy (DAPT) for a longer term than bare-metal stents (BMS). Few studies have examined clinical predictors of DES vs BMS, and variability in provider selection between DES and BMS in clinical practice has not been well described. These insights can inform our understanding of current practice and may identify opportunities to improve decision-making stent selection decinsion-making. In a multicenter registry, 3295 consecutive patients underwent PCI by 158 interventional cardiologists across 10 US sites. Eighty percent of patients with treated with DES. Using hierarchical regression, diabetes mellitus, multivessel disease, health insurance, and white race were independently associated with greater DES use, whereas increasing age, history of hypertension, anticipated surgery, use of warfarin, lower hemoglobin, prior history of bleeding, and treatment of right coronary and left circumflex artery lesions as compared with PCI of left anterior descending artery were associated with lower likelihood of receiving DES. Adjusted rates of DES use across providers varied from 52.3% to 94.6%, and adjusted median odds ratio for DES selection was 1.69. DES selection appeared to reflect physicians’ attempts to balance benefits of DES against risks of prolonged DAPT. Nevertheless, marked residual variability in DES selection across providers persisted after adjusting for predictors of restenosis, bleeding, and other factors. Further studies are needed to better understand drivers of this variability and identify the impact of patient and provider preferences on stent selection at the time of PCI.
KW - Cardiac
KW - catheterization/diagnostic interventional
KW - drug-eluting stents
KW - outcomes research
UR - http://www.scopus.com/inward/record.url?scp=85015285229&partnerID=8YFLogxK
U2 - 10.1002/clc.22693
DO - 10.1002/clc.22693
M3 - Article
C2 - 28300284
AN - SCOPUS:85015285229
SN - 0160-9289
VL - 40
SP - 521
EP - 527
JO - Clinical Cardiology
JF - Clinical Cardiology
IS - 8
ER -