Home > Interventional Cardiology, Journal Club > Journal Club 2 May 2012

Journal Club 2 May 2012

Article

Comparative Effectiveness of Revascularization Strategies

Presenter

LOC

PICO

This was an observational study combining data from  two registries ( ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database)  was linked to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008

Population

patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction

Intervention

The aim of the study was to compare CABG and PCI. Statistical modelling was used to control for confounders between CABG and PCI patients

Comparator

See above

Outcome

Mortality

Findings

Results

Among patients 65 years of age or older who had two-vessel or three-vessel coronary
artery disease without acute myocardial infarction, 86,244 underwent CABG and
103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year,
there was no significant difference in adjusted mortality between the groups (6.24% in
the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence
interval [CI], 0.90 to 1.00). At 4 years, there was lower mortality with CABG
than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results
were noted in multiple subgroups and with the use of several different analytic
methods. Residual confounding was assessed by means of a sensitivity analysis.

Conclusions

In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI.

Discussion Summary

  • The limitations of registry data, particularly the capacity to use statistical modelling to correct for selection bias was uniformly expressed. Specific concerns were raised regarding differences in definitions, accuracy and compliance between surgical and PCI databases; the specific context in which the procedures were performed (United States: surgical report carding, prevalence of low volume PCI operators). The consensus view was that such as analyses are hypotheses generating rather definitive and directive.
  • The statistical methodology was very complex. Propensity score with inverse probability weighting was used to correct for confounders (selection bias). After adjustment the lower mortality of the CABG group persisted. It was noted that there was an early hazard with CABG then a divergence of survival curves in favour of CABG thereafter.  The authors assessed the possibility 0f hidden confounders and provided bounds for prevalence and hazard ratios to account for the observed difference.  Possible unmeasured confounders, such as  measures of frailty were discussed.

The editorial is available here. The supplementary data is available here.

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