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Factors influencing treatment decisions for coronary artery disease after cardiac catheterization. American Heart Association November 18, 2013 Dallas, Texas. Brian R. Englum, MD, Phillip Schulte, PhD, Brian Gulack, MD, Manesh R. Patel, MD, John H. Alexander, MD, MHS, Peter K. Smith, MD.

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factors influencing treatment decisions for coronary artery disease after cardiac catheterization

Factors influencing treatment decisions for coronary artery disease after cardiac catheterization

American Heart Association

November 18, 2013

Dallas, Texas

Brian R. Englum, MD, Phillip Schulte, PhD, Brian Gulack, MD, Manesh R. Patel, MD, John H. Alexander, MD, MHS, Peter K. Smith, MD

disclosure information
Disclosure information
  • Project funding
    • Duke University Medical Center
  • Conflict of interest to disclose
    • None
slide3

Coronary Revascularization Trends in the United States, 2001-2008. JAMA. 2011;305(17):1769-1776.

slide4

Coronary Revascularization Trends in the United States, 2001-2008. JAMA. 2011;305(17):1769-1776.

slide5

Coronary Revascularization Trends in the United States, 2001-2008. JAMA. 2011;305(17):1769-1776.

previous studies cad revasc strategy
Previous studies – CAD revasc strategy
  • SYNTAX
    • PCI vs. CABG
  • FREEDOM
    • PCI vs. CABG in diabetics
  • COURAGE
    • PCI vs. Medical therapy in stable CAD
  • Observational studies
    • Differential benefit: diabetes, smoking, PAD, CHF
purpose
Purpose
  • Describe trends in treatment strategy for CAD
  • Identify factors associated with treatment strategy
    • Revascularization vs. medical therapy
    • PCI vs. CABG
  • Evaluate changes in these factor with evolving PCI technology
methods population
Methods – population
  • Study population
    • Duke Databank for Cardiovascular Disease
    • CAD: ≥ 1 diseased vessel (50% stenosis) by coronary angiography
    • No prior PCI or CABG
  • Study eras
    • Angioplasty: 1986-1995
    • Bare metal stent: 1996-2003
    • Drug-eluting stent: 2004-2012
methods statistical analysis
Methods – statistical analysis
  • Summarized annual rates and patient characteristics by treatment strategy
  • Developed a model of patient characteristics predicting treatment decision
    • Multivariable logistic regression model
    • Stepwise variable selection
  • Estimated interaction of each variable with era in overall model
limitations
Limitations
  • Single institution data
  • Patient preferences
  • Provider reasoning
  • Anatomic details
conclusions
Conclusions
  • Temporal trends in treatment strategies demonstrate dramatic changes over time
  • Decisions in CAD dominated by cardiac factors
  • Comorbidities play a lesser role
  • Most factors influencing treatment decisions appear stable over time
factors associated with treatment decisions revascularization vs medical therapy
Factors associated with treatment decisions Revascularization vs. Medical therapy