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Invited Commentary
February 14, 2020

Coronary Revascularization in the United States—Patient Characteristics and Outcomes in 2020

Author Affiliations
  • 1Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso
JAMA Netw Open. 2020;3(2):e1921322. doi:10.1001/jamanetworkopen.2019.21322

Current indications for coronary revascularization include the relief of ischemia symptoms (ie, angina or angina equivalent) and the improvement of prognosis.1 Available evidence suggests that the prognostic and symptomatic benefits of coronary revascularization depend on the completeness of revascularization. Thus, the ability to achieve complete revascularization should be a pivotal issue when choosing the revascularization strategy. Although contemporary percutaneous coronary interventional (PCI) treatments have been associated with lower risk of restenosis compared with earlier techniques, neither bare metal stents nor drug eluting stents are associated with a survival advantage over balloon angioplasty.2

In this issue of the JAMA Network Open, Alkhouli et al3 report the results of their nationwide representative cohort study that assessed the temporal changes in baseline characteristics of patients undergoing PCI or coronary artery bypass surgery (CABG). The authors report the crude and risk-adjusted in-hospital mortality after PCI or CABG, stratified by clinical indication. The primary findings of their analysis are a decrease in the number of percutaneous and surgical coronary revascularization procedures performed in the United States between 2003 and 2016, with significant changes in the demographic characteristics, socioeconomic status, risk profile, and clinical presentation of patients undergoing coronary revascularization over time, as well as a significant change in the characteristics of the revascularization procedures. Furthermore, they report temporal improvements in in-hospital mortality after CABG but not after PCI across all revascularization indications. Despite some limitations of this analysis, including use of administrative data, lack of data on angiographic findings, laboratory data, characteristics of the PCI or CABG culprit vessel(s), and lack of long-term outcomes after PCI or CABG, these data have important clinical implications for prerevascularization risk assessment by a multidisciplinary heart team regarding need for and choice of revascularization modality and optimization of postrevascularization medical therapies. Furthermore, the lack of PCI mortality improvement over time and a slight increase in mortality among patients with unstable angina or stable ischemic heart disease (SIHD) suggests a need for the development of more effective strategies to further optimize contemporary PCI outcomes.

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