Angioplasty, Bypass Patients: Fewer, Older, Sicker, and Lower SES

The number of Americans undergoing coronary angioplasty and coronary bypass is falling fast, and the people who are getting the coronary revascularization procedures are older, sicker, and more likely to have a lower socioeconomic status than patients in the past, according to research results published today in JAMA Open Network.

Despite the change in the patient profile, Mohamad Alkhouli of the Mayo Clinic and his colleagues found the risk-adjusted mortality rate for bypass surgery has notably declined. They found, though, a slight increase in angioplasty mortality rate for ST-segment elevation myocardial infarction-the most serious, “widowmaker” kind of heart attack. They speculated that the angioplasty mortality rate has increased because clinicians are doing fewer of the procedures. There is a well-documented relationship between volume and outcomes in health care.

The annual coronary angioplasty (percutaneous coronary intervention) volume decreased from 366 per 100,000 American adults in 2003 to 180 per 100,000 in 2016, according to Alkhouli et al.

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The slope of the bypass trend line is similar: The 159 bypasses per 100,000 adults in 2003 slid to 82 per 100,000 in 2016.

Other studies have documented these angioplasty and bypass trends, which are usually explained as consequences of the improvement in the drugs for treating coronary disease and research casting doubt on the benefits of angioplasty for patients with stable coronary artery disease.

As the number have declined, the profile of the patients getting the revascularization procedures has changed, according to Alkhouli et al. The patients are older, more likely to be male and not white, and have a lower socioeconomic status. They are also more likely to be covered by Medicaid. In 2003-2007, 55.9% of angioplasty patients were covered by Medicaid. In 2013-2016, that proportion had grown to 60.9%  Using the Elixhauser comorbidity index, they also found that patients getting angioplasty are sicker.

Angioplasty techniques have also changed, according to Alkhouli’s research. Intravascular ultrasonography and fractional flow reserve measurement has increased while the use of bare metal stents and multivessel angioplasty has decreased. The trends in bypass includes fewer multivessel (>2) and off-pump procedures and greater use of arteries for the graft.