Cardiovascular disease remains the leading cause of mortality and morbidity in the 21st century accounting for about one-fifth of deaths overall each year in the United States. Percutaneous coronary intervention (PCI), used initially in the 1970s, is now the most commonly performed non-surgical procedure for atherosclerotic coronary disease. PCI, in the last three decades, witnessed rapid advancements, both technologically (from balloons to stents and atherectomy devices) as well as in adjunct therapy (antithrombotics, fibrinolytics and antiplatelet agents). The purpose of this dissertation, designed as three research papers, was to capture this evolution and the associated impact on clinical and patient-reported outcomes, in the prospective, multicenter NHLBI-sponsored 1985-86 PTCA (era of balloon angioplasty) and 1997-2004 Dynamic (era of stents, brachytherapy and drug-eluting stents) registries. Temporal trends in clinical practice revealed the heterogeneity in patients (and lesions) undergoing PCI and yet, consistent dramatic improvements were seen in procedural success with reduced need for repeat procedures; little impact was observed in one-year mortality rates. In the Dynamic Registry, significant reductions in one year prevalence and risk of patient-reported angina were observed concurrent to use of new evidence-based secondary pharmacological therapy. In contemporary practice, women and patients with prior/repeat PCI continued to be at high-risk for post-procedural symptoms. Supplemental therapy, following initial PCI, was more often pharmacological with concomitant reduction in bypass surgery and repeat PCI. On average, patient-reported quality of life improved over time and was influenced by both symptom status and the need and type of supplemental therapy. Indeed, these findings reflect the dynamic nature of PCI with an increasingly heterogeneous treatment population and yet favorable procedural outcomes (procedural success, reduced repeat procedures, greater relief of symptoms). More importantly, they highlight the continued lack of impact on mortality and identify symptom-prone subsets in contemporary practice. This time-sensitive documentation is especially fitting given the 300% increase in the number of PCIs since its initial use. From a public health point of view, any treatment modality applied in this magnitude warrants constant surveillance, more so with the emerging safety concerns, and this underscores the importance of well-designed registries.
|Date||25 September 2007|
|Contributors||Kim C. Sutton-Tyrrell, Dr.P.H., M.P.H., Clareann H. Bunker, Ph.D., M.P.H., Sheryl F Kelsey, PhD, Kevin E. Kip, Ph.D., Suresh Mulukutla, MD|
|Publisher||University of Pittsburgh|
|Source Sets||University of Pittsburgh|
|Rights||restricted, I hereby certify that, if appropriate, I have obtained and attached hereto a written permission statement from the owner(s) of each third party copyrighted matter to be included in my thesis, dissertation, or project report, allowing distribution as specified below. I certify that the version I submitted is the same as that approved by my advisory committee. I hereby grant to University of Pittsburgh or its agents the non-exclusive license to archive and make accessible, under the conditions specified below, my thesis, dissertation, or project report in whole or in part in all forms of media, now or hereafter known. I retain all other ownership rights to the copyright of the thesis, dissertation or project report. I also retain the right to use in future works (such as articles or books) all or part of this thesis, dissertation, or project report.|
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