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Contemporary Predictors of Procedural Mortality Among Patients Undergoing
PCI: Results From National Cardiovascular
Data Registry (NCDR)
Eric D Peterson, David Dai, Elizabeth R DeLong, Sunil V Rao,Matthew T Roe, Kalon K L Ho, Mandeep Singh, John S Rumsfeld, Richard E Shaw, William S Weintraub, Ralph G Brindis, John A
Spertus on behalf of the NCDR Registry Participants
Disclosure Statement
Research support provided by the American College of Cardiology National Cardiovascular Data Registry
Background
• Prior models have estimated risks of percutaneous coronary intervention (PCI) mortality. Yet, these have limitations:– Representing older patient populations– Selected centers or regions– Limited number of procedures– Incomplete clinical or angiographic detail– Failed to develop user-friendly formats
Objectives
We propose to use the ACC-NCDR PCI database,the nation’s largest interventional data repository to:
• Develop a contemporary PCI mortality risk model for those receiving primary PCI and elective procedures
• Internally validate the NCDR PCI model– overall and among selected sub-populations
• Determine the incremental prognostic value of angiographic factors beyond pre-cath risk factors
• Develop user-friendly PCI risk score for bedside risk estimation
Methods: Populations
• Development Sample – 302,958 PCI at 470 participating NCDR centers– Jan, 2004 – March, 2006 (v3 data only)– Divided into development (60%) and 1st validation
(40%)
• 2nd Validation Sample– 285,440 PCI at 608 participating NCDR centers– April, 2006 – April, 2007 (v3 data only)
• Exclusions– Not first PCI (57%)– Transfer out (1%)– Missing 2+ candidate variables (<1%)
Methods (2)
• Model Development – Multivariate logistic regression– Backward selection from 34 candidate variables
including demographics, risk factors, cardiac status, cath lab visit, and PCI procedures
• Model Validation– Model discrimination measured using c-index
(ranging from 0.5 for chance discrimination to 1.0 for perfect prediction)
– Model calibration examined by comparing average observed and predicted values within risk groups
Patient Clinical Characteristics (1)
Development (181,775)
1st validation (121,183)
2nd validation (285,440)
Age 63.9±12.1 63.9±12.1 64.1±12.1
Female 33.4% 33.3% 33.3%
Caucasian 87.2% 87.1% 85.6%
BMI (kg/m2) 29.6±6.3 29.7±6.3 29.8±6.3
Prior MI (>7days)
29.1% 29.1% 27.3%
Prior CHF 10.1% 10.0% 9.9%
Diabetes
– Non-insulin 21.5% 21.7% 22.3%
– Insulin 10.0% 10.0% 10.3%
Patient Clinical Characteristics (2)
Development (181,775)
1st validation (121,183)
2nd validation (285,440)
Mean GFR* (+/-SD) 73.6±30.5 73.5±29.0 73.2±28.1
Dialysis Dependent 1.6% 1.5% 1.5%
Cerebral Vascular Disease
10.9% 11.1% 11.1%
Peripheral Vascular Disease
11.7% 11.7% 11.9%
Chronic Lung Disease 16.0% 16.0% 15.8%
Prior PCI 35.1% 35.4% 36.6%
NYHA Class IV 18.3% 18.3% 18.8%
Cardiogenic Shock 1.9% 1.8% 1.7%* Glomerular Filtration Rate (GRF) assessed by MDRD formula
Procedural CharacteristicsDevelopment (181,775)
1st validation (121,183)
2nd validation (285,440)
LVEF 52.7±13 52.7±13 52.7±13
PCI Status
- Elective 49.3% 49.3% 50.2%
- Urgent 36.1% 35.6% 34.7%
- Emergency 14.4% 14.5% 15.0%
- Salvage 0.2% 0.2% 0.2%
Highest Risk Lesion
-pLAD 18.2% 18.2% 18.2%
-Left Main 1.7% 1.8% 1.8%
-Total Occlusion
11.0% 10.7% 14.9%
Multivessel PCI 14.0% 13.9% 14.1%
In Hospital Mortality
1.2%
4.8%
0.7%
1.3%
4.8%
0.7%
1.2%
4.7%
0.6%
0%
1%
2%
3%
4%
5%
6%
Overall STEMI Other
Mo
rta
lity
Ra
te
Develop Sample 1st Validation 2nd Validation
Full and Pre-Cath Risk Models
Full Model † Precath Simple Model
Label O.R. 95% CI Wald Chi-Sq O.R. 95% CI Wald
Chi-Sq
Cardiogenic Shock 8.35 7.40 9.44 1168.
3 12.19 10.86
13.68
1804.7
GFR for STEMI ‡ 0.77 0.74 0.80 181.9 0.77 0.75 0.78 377.6
Age (for age>70) ‡ 1.71 1.57 1.88 125.8 1.76 1.60 1.91 150.9
Age (for age<=70) ‡ 1.55 1.44 1.69 115.3 1.52 1.40 1.64 107.9
PCI Status-Salvage STEMI §
14.55
8.39
25.21 91.1 21.45 12.5
736.6
1 126.3
PCI Status- Emerg. STEMI § 2.07 1.3
0 3.31 9.2 2.65 1.68 4.18 17.6
PCI Status- Urgent STEMI § 1.09 0.6
4 1.83 0.1 1.25 0.75 2.07 0.7
NYHA Class IV for STEMI 1.21 1.0
5 1.39 6.7 1.61 1.46 1.79 81.7
Chronic Lung Disease 1.48 1.31 1.66 43.0 1.52 1.36 1.71 52.9
Peripheral Vascular Disease 1.53 1.3
5 1.74 42.4 1.67 1.48 1.89 67.8
Previous History - CHF 1.29 1.13 1.47 13.9 1.75 1.54 1.98 77.3
† Full model includes: Prior PCI, PreOp IABP, Ejection Fraction, Coronary Lesion >= 50%: Subacute Thrombosis, Total pre-procedure Occlusion, Diabetes treatment, SCAI Lesion Class 2 or 3, BMI for STEMI/non STEMI, Prior Dialysis for STEMI/non STEMI , Highest risk status for non-STEMI, NYHA Class IV for NSTEMI‡ Per 10 unit increase. § Versus Elective
PCI Risk Score System
Age <60 ≥60,<70 ≥70,<80 ≥80
0 4 8 14Cardiogenic Shock No Yes
0 25Prior CHF No Yes
0 5PVD No Yes
0 5CLD No Yes
0 4GFR <30 30-60 60-90 >90
18 10 6 0NYHA Class 4 No Yes
0 4PCI Status (STEMI) Elective Urgent Emergent Salvage
12 15 20 38PCI Status (Other) Elective Urgent Emergent Salvage
0 8 20 42
Points Mortality 0 0.0%5 0.1%10 0.1%15 0.2%20 0.3%25 0.6%30 1.1%35 2.0%40 3.6%45 6.3%50 10.9%55 18.3%60 29.0%65 42.7%70 57.6%75 71.2%80 81.%85 89.2%90 93.8%95 96.5%100 98.0%
Discrimination: C-Indices Sample Full Model Risk Score
N C-Index C-Index
Development 181,775 0.926 0.911 1st Validation 121,183 0.925 0.9012nd validation 285,440 0.924 0.905 Subgroups STEMI 39,889 0.902 0.884 Other 245,551 0.892 0.862
Women 95,106 0.911 0.893 Men 190,334 0.930 0.911
Age>70 92,381 0.901 0.880 Age<=70 193,059 0.927 0.906
Diabetes92,974 0.924 0.903 No Diabetes 192,466 0.923 0.906
Calibration for Full Model
Events by Clinical Risk Groups in Validation Sample
0
5
10
15
20
25
30
35
40
45
50
0.0-0.5 0.5-1.0 1.0-2.0 2.0-5.0 5.0-7.5 7.5-15. 15.-30. 30.+
Predicted Risk Group (%)
Obse
rved
Ris
k (%
)
0
5
10
15
20
25
30
35
40
45
50
0.0-0.5 0.5-1.0 1.0-2.0 2.0-5.0 5.0-7.5 7.5-15. 15.-30. 30.+
Predicted Risk Group (%)
Obse
rved
Ris
k (%
)
Full Model Risk Score
Limitations
• Voluntary participation • Limited auditing of data source• Only internal validation of model• No core lab angiographic readings• No data on functional status• Outcomes limited in in-hospital
mortality
Conclusions
• We developed a highly predictive contemporary mortality model for PCI
• Angiographic variables add modestly to risk assessment
• Model accurate in – Overall, <75 >75, women vs men, DM vs not, – STEMI vs other – Low vs high risk groups
Hospital CharacteristicsDevelopment (181,775)
1st validation (121,183)
2nd validation (285,440)
Number of Beds 463±221 463±220 454±225
Location
- Rural 12.6% 12.6% 12.1%
- Urban 61.0% 61.3% 61.2%
Teaching 60.1% 60.0% 54.6%
Region
- West 14.1% 14.3% 16.2%
- Northeast 9.0% 9.9% 10.4%
- Midwest 36.9% 36.7% 35.8%
- South 36.5% 36.8% 37.6%
Mean Annual PCIVolume
1151±762 1151±763 1159±807
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