Downstream testing and subsequent procedures after coronary computed tomographic angiography following coronary stenting in patients ≥65 years of age

Abstract

Limited data are available on the use of coronary computed tomographic angiography (CCTA) in patients who have received percutaneous coronary intervention (PCI). To evaluate patterns of cardiac testing including CCTA after PCI, we created a retrospective observational dataset linking National Cardiovascular Data Registry CathPCI Registry baseline data with longitudinal inpatient and outpatient Medicare claims data for patients who received coronary stenting from November 1, 2005 through December 31, 2007. In 192,009 patients with PCI (median age 74 years), the first test after coronary stenting was CCTA for 553 (0.3%), stress testing for 89,900 (46.8%), and coronary angiography for 22,308 (11.6%); 79,248 (41.3%) had no further testing. Patients referred to CCTA first generally had similar or lower baseline risk than those referred for stress testing or catheterization first. Compared to patients with stress testing first after PCI, patients who underwent CCTA first had higher unadjusted rates of subsequent noninvasive testing (10% vs 3%), catheterization (26% vs 15%), and revascularization (13% vs 8%) within 90 days of initial testing after PCI (p <0.0001 for all comparisons). In conclusion, despite similar or lesser-risk profiles, patients initially evaluated with CCTA after PCI had more downstream testing and revascularization than patients initially evaluated with stress testing. It is unclear whether these differences derive from patient selection, performance of CCTA compared to other testing strategies, or the association of early adoption of CCTA with distinct patterns of care.

Copyright © 2012 Elsevier Inc. All rights reserved.

Figures

Figure 1

Population flow diagram. Description of: (A) the primary study data set, created using a probabilistic matching algorithm to link the CMS and NCDR CathPCI Registry data set populations; and (B) inclusion, exclusion, and cohort derivation for the CCTA study population. BMS = bare metal stent; CCTA = coronary computed tomography angiography; CMS = Centers for Medicare & Medicaid Services; DES = drug-eluting stent; MRI = magnetic resonance imaging; NCDR = National Cardiovascular Data Registry; PCI = percutaneous coronary intervention; PET = positron emission tomography.

Figure 1

Population flow diagram. Description of: (A) the primary study data set, created using a probabilistic matching algorithm to link the CMS and NCDR CathPCI Registry data set populations; and (B) inclusion, exclusion, and cohort derivation for the CCTA study population. BMS = bare metal stent; CCTA = coronary computed tomography angiography; CMS = Centers for Medicare & Medicaid Services; DES = drug-eluting stent; MRI = magnetic resonance imaging; NCDR = National Cardiovascular Data Registry; PCI = percutaneous coronary intervention; PET = positron emission tomography.

Figure 2

Cumulative incidence of first noninvasive test, coronary angiography, or death within 1 year and at least 60 days after index PCI. Time to the first test (CCTA, stress test, or coronary angiography) or death occurring at least 60 days after index PCI, plotted using cumulative incidence functions accounting for administrative censoring and competing risk of each end point. Cath = invasive coronary angiography; CCTA = coronary computed tomography angiography; PCI = percutaneous coronary intervention; Stress = stress test.

Figure 3

Patterns of noninvasive testing, coronary angiography, and revascularization after index PCI. Testing and procedures after PCI, showing first and second test after PCI and/or any catheterization or revascularization procedures within 90 days of the first test. “Cath yield” is the number of revascularization procedures divided by the number of coronary catheterizations for each testing pattern leading to catheterizations. The diamonds in the top row of the chart indicate the first test during follow-up. The top row of rectangles shows the next test within 90 days; the middle and bottom rows of rectangles show all procedures within 90 days of the first test during follow-up. *Repeat catheterization but no revascularization within 90 days. Cath = invasive coronary angiography; CCTA = coronary computed tomography angiography; Revasc = coronary revascularization (PCI or coronary artery bypass grafting surgery); Stress = stress test.