Impact of National Clinical Guideline recommendations for revascularization of persistently occluded infarct-related arteries on clinical practice in the United States

Abstract

Background: The Occluded Artery Trial (OAT) was a large, randomized controlled trial published in 2006 that demonstrated no benefit to routine percutaneous coronary intervention (PCI) of persistently totally occluded infarct-related arteries (IRA) identified a minimum of 24 hours (on calendar days 3-28) after myocardial infarction (MI). The purpose of this study was to determine the impact of OAT results and consequent change in guideline recommendations for PCI for treatment of persistently occluded IRAs.

Methods: We identified all patients enrolled in the CathPCI Registry, from 2005 to 2008, undergoing catheterization more than 24 hours after MI with a totally occluded native coronary artery and no major OAT exclusion criteria. We examined trends in monthly rates of PCI for occlusions after OAT publication and after guideline revisions. Because reporting of diagnostic catheterizations was not mandatory, we examined trends among hospitals in the highest quartile for reporting of diagnostic procedures.

Results: A total of 28,780 patient visits from 896 hospitals were included. Overall, we found no significant decline in the adjusted monthly rate of PCI of occlusions after publication of OAT (odds ratio [OR], 0.997; 95% confidence interval [CI], 0.989-1.006) or after guideline revisions (OR, 1.007; 95% CI, 0.992-1.022). Among hospitals consistently reporting diagnostic catheterizations, there was no significant decline after OAT publication (OR, 1.018; 95% CI, 0.995-1.042), and there was a trend toward decline after guideline revisions (OR, 0.963; 95% CI, 0.920-1.000).

Conclusion: These findings suggest that the results of OAT and consequent guideline revisions have not, to date, been fully incorporated into clinical practice in a large cross-section of hospitals in the United States.

Figure 1

Unadjusted rates of percutaneous coronary intervention (PCI) for occlusions identified after myocardial infarction (MI) over time. The unadjusted rate of PCI for persistent total coronary artery occlusions after acute MI over the study period is shown, along with 95% confidence intervals, for the overall study population (A), for patients presenting with an ST elevation MI (B), and only those patients treated in hospitals in the highest quartile for reporting of diagnostic catheterizations (C). CI indicates confidence interval; OAT, the Occluded Artery Trial.

Figure 2

Adjusted trends in the rate of percutaneous coronary intervention (PCI) for occlusions identified after myocardial infarction among selected subgroups following guideline revisions. The odds ratios presented here refer to the adjusted odds of receiving PCI for a persistent occlusion, per 30-day increase in time, during the specified time period. They reflect overall trends in the use of PCI for total occlusions during the period from December 2007 to December 2008. CHF indicates congestive heart failure; CI, confidence interval; HMO, health maintenance organization; OR, odds ratio; STEMI, ST elevation myocardial infarction.