Thread by @DrDamluji

*Logical vs. Emotional Truths on the JACC Cardiovascular Intervention Study*

(1/14)

Let me summarize below...

From @JACCJournals

jacc.org/doi/10.1016/j.…

(2/14)

Aims:

The study used the NCDR CathPCI registry to examine

a.The proportion of patients who met the inclusion criteria for ischemia (versus 4 other groups that did not meet the Ischemia-trial criteria).

b.The association between each group with all-cause mortality

(3/14)

Methods:

Patients in the CathPCI registry were categorized into:

1 ACS + Arrest + Cardiogenic Shock (n=538K)
2 Not Ischemia High Risk (n=71K)
3 Not Ischemia (low risk) (n=67K)
4 ***ISCHEMIA-like (n=125k) +stress OR abnormal FFR***
5 Not classified (n=123k)

(4/14)

Results:

Ischemia-like cohort:

Mean age = 67 years
Female patients = 26%
Mostly non-Hispanic Whites
DM = 41%
Highest #RadialFirst utilization = 53%

(5/14) Mortality Rate

Ischemia-like (n=125k) had the lowest mortality: 0.11%
Ischemia-Like: 135 patients out of 124,302 = 0.00108
-
Not Ischemia High-Risk: 481 out of 71,852= 0.00669
Not-Ischemia Low-Risk: 114 out of 67,159 = 0.00169
Not classified: 289 out of 123,899 = 0.00233

(6/14)

Of ALL patients who underwent PCI from 2017 to 2019 | only 13% resemble the ischemia trial population.

(125,302/927,011=13%)

(7/14)

The calculation of this proportion (%) above in (6/14) is what the trialists question.

See 8, 9 and 10 below.

(8/14)

Trialists' Take #1:

Those who have low risk features should not be included in the denominator because they do not benefit from PCI | given data from courage and BARI 2D

(9/14)

Trialists' Take 2:

Those who are not classified (because they do not have stress test reported in NCDR) may included in the ischemia-like cohort if the data was available ~ 50%.

(10/14)

Fair questioning by the trialists, but these are assumptions that cannot be proven and reflected by data.

** I also did not include the discussion on ischemia-CKD study inclusion (slicing the denominator and numerator further).

(11/14)

The trialists' conclusion in the editorial was fair and balanced:

No one knows exactly what the % of Ischemia-population is in practice.

that said...

(12/14)

The principal investigator(s) of JACC Interv Study @jaygirimd are not expected to introduce assumptions when reporting NCDR data from clinical practice.

They tried to estimate the % of patients who most resemble ischemia based on available data..

(13/14)

My take:

1. In the United States, most PCI is performed for ACS (not ischemia like patients)

2. Ischemia criteria when applied to clinical practice is clearly not a majority.

3. The mortality rate with PCI in Ischemia like population is exceedingly small!

Fair?

(14/14)

Good study; good question; good editorial!

Truth is grounded in ethics.

We should distinguish between emotional truths and logical truths!

#cardiotwitter

*be
*were

Sorry!