SHA24/037001

Variation in the PCI to CABG Ratio: single centre experience in KSA& international comparison

Ahmed A Arifi, Hani K Najm,Munir Ahmad,Ali AL Ghamdi,Rawdene Van Onselen, Muayed Al Zaibag King Abdulaziz cardiac sciences King abdulaziz medical city

12.3.2013

AAA

Study Objectives ď Ž

ď Ž

Over the past 20 years, the use of percutaneous coronary intervention (PCI), for myocardial revascularization has seen a dramatic increase.

Although the evidence available is similar, there are a variation in the relative distribution of PCI to CABG among centers and regions.

Study Objectives ď Ž We

sought to review our current practice and study the distirbution and ratio of our PCI to CABG

Background:I” the Evidence”

SYNTAX TRIAL Designed to look at 5 years out come and MACCE ALL COMERS TRIAL 35% OF PATIENTS STRAIGHT TO CABG

How won" the SYNTAX trial ď Ž

ď Ž

A surgeon will say the longer you go in follow-up, the better surgery looks. We knew this was going to look good four to five years out. an interventionalist, he might say, 'We don't use Taxus stents any more, we use the everolimus-eluting Xience, and the discussion will go on.

189,793 patients from ACC (PCI) and STS (CABG) Databases

At 4 years survival benefits of CABG of 4.4%: HR 0.79 Survival benefits of CABG increases with time

Guide lines recommendations ESC &ACC

Background II 



Variation in PCI to CABG in real life Practice .

Adherence to Guide lines

A cardiac catheterization laboratory database used by 19 hospitals in New York State between January 1, 2005, and August 31, 2007. 16142 cathether lab patient.

A cardiac catheterization laboratory database used by 19 hospitals in New York State between January 1, 2005, and August 31, 2007. 16142 cathether lab patient.

Conclusions—Patients with coronary artery disease receive more recommendations for PCI and fewer recommendations for CABG surgery than indicated in the American College of Cardiology/American Heart Association guidelines.

Conclusions—-There are substantial regional and statewide differences in the utilization of PCI versus CABG among cardiac centers in New York, possibly related to patient characteristics, physician biases, and hospital culture. Understanding these disparitiesmay facilitate the selection of the most appropriate, effective, and evidence-based revascularization strategy.

The objective of this review was to determine whether patients undergoing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) (1) understand the aims of the proposed intervention, and (2) whether they are offered alternative and potentially more effective therapies, as required for the process of informed consent.

Methods and Results 







We carried a review of our prospectively collected data -20012011 Cath lab and the cardiac surgery data base KACC adopt a multidiscplinary cardiology & cardiac surgery meeting approach, twice a week, However, not for all cases of PCI

Methods and Results Over the study period 4313 and 2531 cases of PCI and CABG respectively.  PCI volume shows a yearly increase of almost 50%  CABG volume stayed static with an average of 230 cases/year 

Number Diagnostic LHC vs.

PCI per year 2001 - 2011 1000 900 800 700 600 500 400 300 200 100 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Diag LHC

PCI

Linear (PCI)

Diagnostic LHC vs.PCI Year

LHC

# PCI & %

2001

528

157

29.7%

2002

483

228

47%

2003

557

222

39.8%

2004

574

359

62.5%

2005

643

468

72.7%

2006

773

392

50.7%

2007

678

405

59.7%

2008

734

483

65.8%

2009

630

450

71.4%

2010

738

561

76%

2010

908

598

65.8%

Diagnostic LCH & PCI vs. Isolated CABG per year for 2001 - 2011 1000 900 800 700 600 500 400 300 200 100 0

Diag LHC PCI CABG Linear (PCI) Linear (CABG)

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

CABG vs.PRE OP PCI 2001 - 2011 Year

CABG

# PCI & %

2001

212

20

9.4%

2002

202

25

12.3%

2003

218

24

11%

2004

183

20

11%

2005

250

18

7.2%

2006

246

15

6.1%

2007

250

25

10%

2008

226

21

9.29%

2009

213

22

10.33%

2010

245

36

14.7%

2010

286

46

16.1%

Isolated CABG with pre op PCI (regardless of where PCI preformed) 2001 - 2011 350 300 250 200 150 100 50

20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11

0

CABG Pre OP PCI Linear (Pre OP PCI)

PCI to CABG Ratio  Low

to medium (2.0 to 2.7)  Medium to high (2.7 to 3.2)  High (>3.2) Tu JV, Ko DT, Guo H et al.

Determinants of variations in coronary revascularization practices. CMAJ 2011; DOI:10.1503/cmaj.11107

PCI/CABG Ratio : the comparison 





New York States, the average PCI/CABG ratio increased from 1.12 in 1994 to 5.14 in 2008.

In Manhattan increasead form 1.19 in 1994 to reach 8.04 in 2008.

In Ontario Canada the ratio varied from 1.6 to 4.6 in 19 centers.

Tu JV, Ko DT, Guo H et al. Determinants of variations in coronary revascularization practices.

CMAJ 2011; DOI:10.1503/cmaj.11107

PCI/CABG Ratio : the comparison 





In KACC the PCI to CABG ratio increased over the study period from 1.1 in 2002 to 2.7 in 2011.

This place the KACC in the low to medium class ratio The shift was related to the progressive increase in the PCI volume while CABG volume remained static.

Conclusion 





This is the first reported ratio of PCI to ACBG in the Region.

The current trend in our centre is encouraging.

Further support to the heart team approach will facilitate the selection of the appropriate and the evidence based revascularisation strategy to our patients