Trend in percutaneous coronary intervention volume following the COURAGE and BARI-2D trials: Insight from over 8.1 million percutaneous coronary interventions

BackgroundCOURAGE and BARI-2D have questioned the utility of routine revascularization for the prevention of cardiovascular events in patients with stable ischemic heart disease (SIHD). On the other end of the spectrum, a routine invasive strategy in patients with acute coronary syndrome (ACS) is superior to a conservative strategy. The impact of the above trials on the trend in percutaneous coronary intervention (PCI) volume for SIHD and ACS is not known.MethodsData from the 2001-2011 Nationwide Inpatient Sample for discharges with PCI were used. The trend in PCI volume over time was analyzed, especially in relation to the COURAGE (2007) and the BARI-2D (2009) trials. Age and gender adjusted PCI rates were calculated using direct standardization method.ResultsAmong the 8,150,764 PCI procedures, there was a steady increase in PCI volumes until the publication of the COURAGE/BARI-2D trials after which the volume decreased. Compared to the peak volume of 909,331 in 2006, PCI volume declined by 38% to 562,036 in 2011 (P < 0.0001); driven by a 60% decrease in PCI for SIHD from 409,199 in 2006 to 160,707 in 2011 (P < 0.0001). Moreover, there was a 20% decrease in PCI for ACS from 500,132 in 2006 to 401,330 in 2011 (P < 0.0001) driven by a significant decrease in PCI for unstable angina. Results were similar in diabetics with a decline in the volume after BARI-2D trial, although the decline was less dramatic.ConclusionThe 11-year trend indicates a substantial impact of COURAGE/BARI-2D on SIHD PCI volumes with an unintended consequence of lower PCI volumes for ACS.