Introduction:
In this study, we examined the real-world impact of research evidence on the use of and indications for percutaneous coronary intervention (PCI) (before and after COURAGE Trial publication) and the choice of drug eluting stents (DES) vs. bare metal stents (BMS) (before and after FDA warnings about risk of DES thrombosis).
Methods:
We used hospital discharge data from Florida to calculate the distribution of primary indication for PCI and the % of PCI patients who received DES, BMS, or no stent on a quarterly basis from Jan 2006 - Jun 2012. We plotted stent trends separately for patients with principal diagnosis of STEMI (n=66,054), NSTEMI/ICS (n=140,886), and stable CHD (n=117,307).
Results:
Since 2006, the % of PCIs with a primary indication of either STEMI or NSTEMI has steadily increased, while the % with an indication of stable CHD declined from 45% to 28%. In early 2006, DES were used in 86.9% of NSTEMI patients, 87.5% of stable CHD patients, and 81.4% of STEMI patients. DES use first declined in all diagnosis groups in Q3 2006, coinciding with the release of meta-analysis results showing higher risk of late stent thrombosis for DES vs. BMS. The lowest rate of DES usage was reached in Q1 2008 (45% for STEMI, 63% for NSTEMI, 67% for stable CHD). However, by Q2 2012, DES use had increased to 60% in STEMI cases, 75% in NSTEMI cases, and 76% in stable CHD cases. The percent of PCI patients who received no stent has remained stable at < 9% since 2006, regardless of diagnosis.
Conclusions:
The COURAGE Trial showed no benefit of PCI over medical treatment in stable coronary heart disease (CHD). From 2006-2012, the proportion of PCIs with an indication of stable CHD declined from 45% to 28%, indicating a real-world response to evidence. Similarly, following controversy about long-term effects of DES, off-label use, and patient compliance with thienopyridines which began in late 2006, there was an immediate resurgence in use of BMS, especially for STEMI. However, the proportion of patients receiving DES has steadily increased since early 2008, regardless of primary indication. More research on the influence of provider and hospital characteristics on response to evidence is needed.
Stent thrombosis in real-world patients: a comparison of drug-eluting with bare metal stents
