Trends in Cause of Death After Percutaneous Coronary Intervention

Abstract

Background-The impact of changing demographics on causes of long-term death after percutaneous coronary intervention (PCI) remains incompletely defined. Methods and Results-We evaluated trends in cause-specific long-term mortality after index PCI performed at a single center from 1991 to 2008. Deaths were ascertained by scheduled prospective surveillance. Cause was determined via telephone interviews, medical records, autopsy reports, and death certificates. Competing-risks analysis of cause-specific mortality was performed using 3 time periods of PCI (1991-1996, 1997-2002, and 2003-2008). Final follow-up was December 31, 2012. A total of 19 077 patients survived index PCI hospitalization, of whom 6988 subsequently died (37%, 4.48 per 100 person-years). Cause was determined in 6857 (98.1%). Across 3 time periods, there was a 33% decline in cardiac deaths at 5 years after PCI (incidence: 9.8%, 7.4%, and 6.6%) but a 57% increase in noncardiac deaths (7.1%, 8.5%, and 11.2%). Only 36.8% of deaths in the recent era were cardiac. Similar trends were observed regardless of age, extent of coronary disease, or PCI indication. After adjustment for baseline variables, there was a 50% temporal decline in cardiac mortality but no change in noncardiac mortality. The decline in cardiac mortality was driven by fewer deaths from myocardial infarction/sudden death (P<0.001) but not heart failure (P=0.85). The increase in noncardiac mortality was primarily attributable to cancer and chronic diseases (P<0.001). Conclusions-This study found a marked temporal switch from predominantly cardiac to predominantly noncardiac causes of death after PCI over 2 decades. The decline in cardiac mortality was independent of changes in baseline clinical characteristics.

Stress Echocardiography Positivity Predicts Cancer Death

“…Recently, Poulin et al have shown that the use of adenosine stress for perfusion imaging is associated with higher risk of death than exercise testing, and this difference in mortality is mainly driven by noncardiac death. The positivity for perfusion criteria was predictive of noncardiac death at univariable, but not multivariable analysis 24. This is different from our findings but can be explained by different patient selection criteria and sample sizes.…”

“…To our knowledge, there are no studies evaluating the changing trends in causes of death after SE testing, although emerging data from coronary angiography24 or myocardial perfusion stress imaging25 data suggest that the coronary atherosclerotic burden assessed by functional (stress‐induced perfusion defects) or anatomical (CAD by coronary angiography) proxies predict noncardiac and especially cancer death more than cardiac death. Recently, Poulin et al have shown that the use of adenosine stress for perfusion imaging is associated with higher risk of death than exercise testing, and this difference in mortality is mainly driven by noncardiac death.…”

“…Second, the lack of independent predictive value of inducible ischemia by perfusion imaging in the study by Poulin et al may be because of sample size limitations. With a sample size of 1511 patients and a follow‐up of 4.0 years, only 50 noncardiac and 18 cardiac deaths occurred, with a high risk of collinearity (between stress mode and perfusion defect presence) and overfitting of the Cox model, leading to a significant type II (not seeing an existing difference) error 24. Third, the study clustered together all causes of noncardiac death, whereas we could separate cancer causes, where most of the difference was found.…”

“…Previous studies have evaluated the changing trends in causes of death after percutaneous coronary interventions (PCIs), which is a more direct index of anatomic coronary artery disease, of which SE results are only a proxy. In a retrospective analysis of >19 000 patients surviving an index PCI, Spoon et al found a 33% decline in cardiac death at 5 years after PCI, but a 57% increase in noncardiac death, primary attributable to cancer, which accounted for 26.2% of deaths (4.3% from hematologic malignancies) during 5 years of follow‐up after PCI 24. For men and women aged at least 60 years at the time of the first PCI, excess risk of potentially fatal cancers attributable to radiation ranged from 0.4% to 4% 26, 27.…”

Extended Duration Dual Antiplatelet Therapy and Mortality: A Systematic Review and Meta-Analysis

“…However, with improved recognition and treatment of these conditions, the associated mortality of these ischemic events may be less than in prior eras, and the relative contributions of noncardiovascular causes of death represent a growing proportion of mortality. 26,27 In light of the neutral association with mortality, and the offsetting ischemic benefits and bleeding risks, the decision to continue DAPT beyond what is currently recommended in guidelines should be tailored to the specific anticipated risks for individual patients.…”