Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO (S.A.S., R.S.B., S.W.W., J.A.V.).
Rocky Mountain Regional VA Medical Center, Aurora, CO (A.H., S.W.W., J.A.V.).
Circ Cardiovasc Qual Outcomes. 2023 Mar;16(3):e008949. doi: 10.1161/CIRCOUTCOMES.122.008949. Epub 2023 Feb 1.
Guidelines recommend maximal antianginal medical therapy before attempted coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The degree to which this occurs in contemporary practice is unknown. We aimed to characterize the frequency and variability of preprocedural use of antianginal therapy and stress testing within 3 months before PCI of CTO (CTO PCI) across a nationally integrated health care system.
We identified patients who underwent attempted CTO PCI from January 2012 to September 2018 within the Veterans Affairs Healthcare System. Patients were categorized by management before CTO PCI: presence of ≥2 antianginals, stress testing, and ≥2 antianginals and stress testing within 3 months of PCI attempt. Multivariable logistic regression and inverse propensity weighting were used for adjustment before trimming, with median odds ratios calculated for variability estimates.
Among 4250 patients undergoing attempted CTO PCI, 40% received ≥2 antianginal medications and 24% underwent preprocedural stress testing. The odds of antianginal therapy with more than one medication before CTO PCI did not change over the years of the study (odds ratio [OR], 1.0 [95% CI, 0.97-1.04]), whereas the odds of undergoing preprocedural stress testing decreased (OR, 0.97 [95% CI, 0.93-0.99]), and the odds of antianginal therapy with ≥2 antianginals and stress testing did not change (OR, 0.98 [95% CI, 0.93-1.04]). Median odds ratios (MOR) showed substantial variability in antianginal therapy across hospital sites (MOR, 1.3 [95% CI, 1.26-1.42]) and operators (MOR, 1.35 [95% CI, 1.26-1.63]). Similarly, preprocedural stress testing varied significantly by site (MOR, 1.68 [95% CI, 1.58-1.81]) and operator (MOR, 1.80 [95% CI, 1.56-2.38]).
Just under half of patients received guideline-recommended management before CTO PCI, with significant site and operator variability. These findings suggest an opportunity to reduce variability in management before CTO PCI.
指南建议在尝试经皮冠状动脉介入治疗（PCI）治疗慢性完全闭塞性冠状动脉（CTO）之前，采用最大的抗心绞痛药物治疗。目前尚不清楚这种情况在当代实践中的发生频率和变化。我们旨在描述在全国一体化医疗保健系统中，在尝试 CTO PCI 前 3 个月内，抗心绞痛药物治疗和压力测试在 CTO PCI 前的使用频率和变异性。
我们从 2012 年 1 月至 2018 年 9 月期间，在退伍军人事务部医疗保健系统中确定了接受尝试 CTO PCI 的患者。根据 CTO PCI 前的管理情况对患者进行分类：存在≥2 种抗心绞痛药物、压力测试和≥2 种抗心绞痛药物和压力测试。在修剪前使用多变量逻辑回归和逆倾向加权进行调整，并计算中位数优势比以评估变异性估计值。
在 4250 名接受尝试 CTO PCI 的患者中，40%接受了≥2 种抗心绞痛药物治疗，24%接受了术前压力测试。在 CTO PCI 前，抗心绞痛药物治疗中使用一种以上药物的可能性并未随着研究年限的变化而改变（比值比[OR]，1.0[95%CI，0.97-1.04]），而接受术前压力测试的可能性降低（OR，0.97[95%CI，0.93-0.99]），且使用≥2 种抗心绞痛药物和压力测试的可能性无变化（OR，0.98[95%CI，0.93-1.04]）。中位数优势比（MOR）显示医院之间的抗心绞痛治疗存在很大差异（MOR，1.3[95%CI，1.26-1.42]）和操作人员（MOR，1.35[95%CI，1.26-1.63]）。同样，术前压力测试也因站点（MOR，1.68[95%CI，1.58-1.81]）和操作人员（MOR，1.80[95%CI，1.56-2.38]）而存在显著差异。
近一半的患者在 CTO PCI 前接受了指南推荐的治疗，存在明显的站点和操作人员的变异性。这些发现表明有机会减少 CTO PCI 前的治疗变异性。
