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Comparative-Effectiveness of Revascularization Versus Routine Medical Therapy for Stable Ischemic Heart Disease: A Population-Based Study

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ABSTRACT

BACKGROUND

Randomized studies have shown optimal medical therapy to be as efficacious as revascularization in stable ischemic heart disease (IHD). It is not known if these efficacy results are reflected by real-world effectiveness.

OBJECTIVE

To evaluate the comparative effectiveness of routine medical therapy versus revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in stable IHD.

DESIGN

Observational cohort study.

PATIENTS

Stable IHD patients from 1 October 2008 to 30 September 2011, identified using a Registry of all angiography patients in Ontario, Canada.

INTERVENTION

Revascularization, defined as PCI/CABG within 90 days after index angiography.

MAIN MEASURES

Death, myocardial infarction (MI) or repeat PCI/CABG. Revascularization was compared to medical therapy using a) multivariable Cox-proportional hazard models with therapy strategy treated as a time-varying covariate; and b) a propensity score matched analysis. Post-angiography medication use was determined.

KEY RESULTS

We identified 39,131 stable IHD patients, of whom 15,139 were treated medically, and 23,992 were revascularized (PCI = 15,604; CABG = 8,388). Mean follow-up was 2.5 years. Revascularization was associated with fewer deaths (HR 0.76; 95 % CI 0.68–0.84; p < 0.001) ,MIs (HR 0.78; 95 % CI 0.72–0.85; p < 0.001) and repeat PCI/CABG (HR 0.59; 95 % CI 0.50–0.70; p < 0.001) than medical therapy. In the propensity-matched analysis of 12,362 well–matched pairs of revascularized and medical therapy patients, fewer deaths (8.6 % vs 12.7 %; HR 0.75; 95 % CI 0.69–0.81; p < 0.001) , MIs (11.7 % vs 14.4 %; HR 0.84; 95 % CI 0.77–0.93 p < 0.001) and repeat PCI/CABG ( 17.4 % vs 24.1 %;HR 0.67; 95 % 0.63–0.71; p < 0.001) occurred in revascularized patients, over the 4.1 years of follow-up.

The revascularization patients had higher uptake of clopidogrel (70.3 % vs 27.2 %; p < 0.001), β-blockers (78.2 % vs 76.7 %; p = 0.010), and statins (94.7 % vs 91.5 %, p < 0.001) in the 1-year post-angiogram.

CONCLUSIONS

Stable IHD patients treated with revascularization had improved risk-adjusted outcomes in clinical practice, potentially due to under-treatment of medical therapy patients.

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Acknowledgements

Contributors

The authors acknowledge that the clinical registry data used in this publication are from the Cardiac Care Network of Ontario and its member hospitals. The Cardiac Care Network of Ontario serves as an advisory body to the MOHLTC, and is dedicated to improving the quality, efficiency, access and equity of adult cardiovascular services in Ontario, Canada. The Cardiac Care Network of Ontario is funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC). This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the MOHLTC. The funding organizations did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the article. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.

Funders

This study is funded through an operating grant from the Canadian Institute of Heath Research (CIHR), and in part by research funding from the Schulich Heart Centre at Sunnybrook Health Sciences Centre and the Sunnybrook Research Institute. The opinions, results, and conclusions reported in this article are those of the authors. The funding sources had no role in the study’s design, conduct or reporting.

Dr H. Wijeysundera is supported by a Distinguished Clinical Scientist Award from the Heart and Stroke Foundation of Canada. Dr Tu is supported by a Career Investigator award from the Heart and Stroke Foundation and a Canada Research Chair in Health Services Research. Dr. Ko is supported by a Clinician Scientist Phase II personnel award from the Heart and Stroke Foundation, Ontario Provincial Office. Dr Austin is supported in part by a Career Investigator Award from the Heart and Stroke Foundation. Dr D. Wijeysundera is supported by a Clinician Scientist Salary award from CIHR, and a Merit Award from the Department of Anesthesia at the University of Toronto.

Conflicts of Interest

The authors have no relevant conflicts of interest.

Author information

Authors and Affiliations

  1. Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite A202, Toronto, ON, M4N3M5, Canada

    Harindra C. Wijeysundera MD, PhD, Maria C. Bennell MSc, MPH, Dennis T. Ko MD, MSc & Jack V. Tu MD, PhD

  2. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Harindra C. Wijeysundera MD, PhD, Dennis T. Ko MD, MSc, Jack V. Tu MD, PhD & Duminda N. Wijeysundera MD, PhD

  3. Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada

    Harindra C. Wijeysundera MD, PhD, Feng Qiu MSc, Dennis T. Ko MD, MSc, Jack V. Tu MD, PhD, Duminda N. Wijeysundera MD, PhD & Peter C. Austin PhD

  4. Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada

    Harindra C. Wijeysundera MD, PhD & Duminda N. Wijeysundera MD, PhD

  5. Department of Anesthesia, Toronto General Hospital and University of Toronto, Toronto, ON, Canada

    Duminda N. Wijeysundera MD, PhD

Authors
  1. Harindra C. Wijeysundera MD, PhD
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  2. Maria C. Bennell MSc, MPH
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  3. Feng Qiu MSc
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  4. Dennis T. Ko MD, MSc
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  5. Jack V. Tu MD, PhD
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  6. Duminda N. Wijeysundera MD, PhD
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  7. Peter C. Austin PhD
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Corresponding author

Correspondence to Harindra C. Wijeysundera MD, PhD.

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Wijeysundera, H.C., Bennell, M.C., Qiu, F. et al. Comparative-Effectiveness of Revascularization Versus Routine Medical Therapy for Stable Ischemic Heart Disease: A Population-Based Study. J GEN INTERN MED 29, 1031–1039 (2014). https://doi.org/10.1007/s11606-014-2813-1

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