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Contemporary Predictors of Procedural Mortality Among Patients Undergoing PCI: Results From National Cardiovascular Data Registry (NCDR).

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  1. 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

  2. Disclosure Statement • Research support provided by the American College of Cardiology National Cardiovascular Data Registry

  3. 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

  4. 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

  5. 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%)

  6. 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

  7. Patient Clinical Characteristics (1)

  8. Patient Clinical Characteristics (2) * Glomerular Filtration Rate (GRF) assessed by MDRD formula

  9. Procedural Characteristics

  10. In Hospital Mortality

  11. Full and Pre-Cath Risk Models † 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

  12. PCI Risk Score System 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% Age <60 ≥60,<70≥70,<80≥80 0 4 8 14 Cardiogenic Shock No Yes 0 25 Prior CHF No Yes 0 5 PVD No Yes 0 5 CLD No Yes 0 4 GFR <30 30-60 60-90 >90 18 10 6 0 NYHA Class 4 No Yes 0 4 PCI Status (STEMI) Elective Urgent Emergent Salvage 12 15 20 38 PCI Status (Other) Elective Urgent Emergent Salvage 0 8 20 42

  13. 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 0.901 2nd 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 Diabetes 92,974 0.924 0.903 No Diabetes 192,466 0.923 0.906

  14. Calibration for Full Model

  15. Events by Clinical Risk Groups in Validation Sample Full Model Risk Score

  16. 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

  17. 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

  18. Hospital Characteristics

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