Temporal trends and inequalities in coronary angiography utilization in the management of non-ST-Elevation acute coronary syndromes in the U.S.

Abstract

Coronary angiography (CA) is the basis of an invasive management strategy in non-ST elevation acute coronary syndromes (NSTEACS). There are limited contemporary data on national temporal trends in utilization of CA in different patient subgroups. We sought to investigate temporal trends, predictors and clinical outcomes associated with the use of CA in the US. Using the Nationwide Inpatient Sample (NIS) from 2004–2014, we identified all inpatient admissions, age ≥18, with a primary diagnosis of NSTEACS. Descriptive statistics and multivariable logistic regression models were used to investigate temporal trends, predictors and clinical outcomes associated with CA. From a total of 4,380,827 patients, 57.5% received CA during the study period and were more likely to be male, younger and less comorbid as defined per Charlson comorbidity index. The proportion of patients receiving CA increased from 48.5% to 68.5%, however, higher proportional increase was observed in males (53.9% to 69.4% Ptrend < 0.001) and those age ≤60 years (59.0% to 77.9% Ptrend < 0.001). Prior history of CABG (OR 0.33 95%CI 0.35–0.36), previous PCI (OR 0.84 95%CI 0.83–0.86) and previous AMI (OR 0.65 95%CI 0.64–0.67) were inversely related with receipt of CA. Receipt of CA was strongly associated with decreased odds of in-hospital mortality (OR 0.38 95%CI 0.36–0.40). In this national analysis, we observed a temporal increase in utilization of CA albeit slower adoption was noted in older, women and more comorbid patients. The risk-treatment paradox wherein patients who are most likely to benefit were less likely to receive CA persists even in contemporary practice.

Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data

“…Data from the National Inpatient Sample database in the USA showed that coronary angiography was done in 78% of patients with NSTEMI aged 60 years or younger, compared with 38% of patients aged 81 years or older. 5 In our study, 49% of eligible patients underwent invasive management during their index admission. These differences do not necessarily reflect ageism, rather they reflect insufficient data to guide clinical practice.…”

“… 10 , 11 Studies of temporal trends using registry data from the USA and Europe suggest that over the past 15 years the progressive switch from a non-invasive to more invasive approach in older patients with NSTEMI has been accompanied by declining mortality. 5 , 29 , 30 …”

“…Only 38% of patients with NSTEMI who are aged 81 years or older receive a coronary angiogram, compared with 78% of those aged 60 years or younger. 5 …”

Patient and Cardiologist Perspectives on Shared Decision Making in the Treatment of Older Adults Hospitalized for Acute Myocardial Infarction

“…Among older adults with acute myocardial infarction (AMI), there has been an increasing use of invasive coronary angiography and coronary revascularization in the United States, 1 Canada, 2 and Europe 3 over recent decades. For example, in the United States, the use of invasive coronary angiography for non-ST-elevation acute coronary syndromes increased from 49.7% in 2004 to 66.0% in 2014 among patients aged 71 to 80 years and from 27.2% to 37.9% among patients >80 years.…”

“…For example, in the United States, the use of invasive coronary angiography for non-ST-elevation acute coronary syndromes increased from 49.7% in 2004 to 66.0% in 2014 among patients aged 71 to 80 years and from 27.2% to 37.9% among patients >80 years. 1 While these procedures have multiple benefits, including the potential for reduced mortality and recurrent AMI, 4,5 they also confer risk. This risk increases with advancing age, as physiologic changes coupled with comorbidities increase the risk of treatment-related complications, including bleeding, acute kidney injury, vascular complications, and stroke.…”