Clinical Research
Coronary Artery Disease
Assessing the Association of Appropriateness of Coronary Revascularization and Clinical Outcomes for Patients With Stable Coronary Artery Disease

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Objectives

The study assessed the appropriateness of coronary revascularization in Ontario, Canada, and examined its association with longer-term outcomes.

Background

Although appropriate use criteria for coronary revascularization have been developed to improve the rational use of cardiac invasive procedures, it is unknown whether greater adherence to appropriateness guidelines is associated with improved clinical outcomes in stable coronary artery disease.

Methods

A population-based cohort of stable patients undergoing cardiac catheterization was assembled from April 1, 2006, to March 31, 2007. The appropriateness for coronary revascularization at the time of coronary angiography was retrospectively adjudicated using the appropriate use criteria. Clinical outcomes between coronary revascularization and medical treatment without revascularization, stratified by appropriateness categories, were compared.

Results

In 1,625 patients with stable coronary artery disease, percutaneous coronary intervention or coronary artery bypass grafting was only performed in 69% who had an appropriate indication for coronary revascularization. Coronary revascularization was associated with a lower adjusted hazard of death or acute coronary syndrome (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.42 to 0.88) at 3 years compared with medical therapy in appropriate patients. The rate of coronary revascularization was 54% in the uncertain category and 45% in the inappropriate category. No significant difference in death or acute coronary syndrome between coronary revascularization and no revascularization in the uncertain category (HR: 0.57; 95% CI: 0.28 to 1.16) and the inappropriate category (HR: 0.99; 95% CI: 0.48 to 2.02) was observed.

Conclusions

Using the appropriateness use criteria, we identified substantial underutilization and overutilization of coronary revascularization in contemporary clinical practice. Underutilization of coronary revascularization is associated with significantly increased risks of adverse outcomes in patients with appropriate indications.

Key Words

appropriateness
coronary revascularization
outcomes

Abbreviations and Acronyms

ACS
acute coronary syndrome
CABG
coronary artery bypass grafting
CI
confidence interval
CCN
Cardiac Care Network of Ontario
HR
hazard ratio
PCI
percutaneous coronary intervention

Cited by (0)

The Variations in Revascularization Practice in Ontario (VRPO) project was supported by an operating grant from the Ontario Ministry of Health and Long-Term Care. The analysis of this study was supported by a Canadian Institutes of Health Research (CIHR) operating grant MOP (102487). The Cardiac Care Network of Ontario and the Institute for Clinical Evaluative Sciences are funded by the Ontario Ministry of Health and Long-Term Care. Dr. Ko is supported by a CIHR New Investigator Award. Dr. Tu is supported by a Canada Research Chair in Health Services Research and a Career Investigator Award from the Heart and Stroke Foundation of Ontario. Dr. Feindel has received financial support from Edwards Lifesciences. Dr. Cohen has received financial support from Abbott Vascular, Medtronic, and Boston Scientific. All other authors have reported they have no relationships relevant to the contents of this paper to disclose.