Difference in a decade: percutaneous coronary interventions in Australia

Abstract

Percutaneous coronary intervention (PCI) is the most common revascularisation strategy for coronary artery disease. PCI guidelines have evolved rapidly over the past 15 years. Contemporary developments include a preference for radial rather than femoral access, the development of drug-eluting stents (DES) and newer antiplatelet agents, and a focus on timely revascularisation (door-toballoon time) among ST-elevation myocardial infarction (STEMI) patients. Further, concerns have been raised regarding outcome differences among specific population groups, including females. The Melbourne Interventional Group registry has collected PCI data from numerous Victorian public hospitals since 2004, the longest continuous period of data available on Australian PCI practice and outcomes. In this report, we compare early (2005–2008; 10 623 procedures) and contemporary (2015–2018; 14 439 procedures) cohorts to assess response to changing guidelines. The contemporary PCI cohort was older (12% >80 years in 2015–2018 vs 10% in 2005–2008), more commonly male (78% vs 75%), with higher rates of obesity, sleep apnoea, insulin-dependent diabetes and current smoking. Contemporary PCI indications were more often nonSTEMI (28% vs 25%), STEMI (31% vs 27%), cardiogenic shock (CS) (4% vs 3%) and out-of-hospital cardiac arrest (OHCA) (4% vs 1%), all P < 0.01. Procedural practice has changed with the contemporary cohort having higher radial access rates (57% vs 4%), higher DES use (83% vs 44%) and higher lesion complexity (such as left main or ostial location, longer lesions or American College of Cardiology/American Heart Association class B2/C). Rates of in-stent restenosis and stent thrombosis requiring PCI were lower, reflecting improved stent technology and pharmacotherapy strategies over time. Door-to-balloon times for STEMI were more frequently <90 min (62% vs 47%). Medication use at 30 days demonstrated high (>95%) adherence to aspirin and a second antiplatelet (ticagrelor is now the most frequently prescribed), and higher rates of cholesterollowering medication and beta-blocker use. Despite procedural improvements, contemporary mortality rates were higher at 30 days (3.9% vs 2.2%, P < 0.01) and 12 months (7.1% vs 4.4%, P < 0.01). Rates of 30-day stroke (0.7% vs 0.4%, P < 0.01) and major adverse cardiovascular events (6.8% vs 5.5%, P < 0.01) were higher, while 30-day target vessel revascularisation, myocardial infarction and coronary bypass surgery rates were similar. Major bleeding rates significantly declined. Thirty-day mortality among patient populations undergoing PCI is presented (Fig. 1). Of concern is the persistent difference in mortality