Atrial Fibrillation and Stent Selection (Bare Metal vs Drug Eluting) (from Medicare Claims)

Abstract

In treating coronary artery disease, many factors influence the choice of bare metal stent (BMS) or drug-eluting stent (DES), including bleed risk and suitability for prolonged dual antiplatelet therapy. Atrial fibrillation (AF) further complicates this choice, due to common use of anticoagulation. We examined stent selection in the United States by AF status and across academic medical centers (AMCs) to explore how cardiologists are managing this complex choice. Using a 100% Medicare denominator file and associated claims (2008 to 2012), we identified patients over age 65 receiving inpatient coronary artery stents. We measured BMS and DES use in patients with AF and in patients without AF and assessed variation in stent choice across AMCs, adjusting for differences in age, gender, and race. We identified 898,788 stent episodes among elderly Medicare beneficiaries. BMS, as a percentage of total inpatient stent episodes, decreased from 2008 to 2012, in patients with AF (42% to 34%) and in patients without AF (32% to 23%). Across AMCs, adjusted stent choice varied substantially, but more so for patients with AF (2008 to 2012 median BMS 44% to 39%, annual interquartile ratios range 1.8 to 2.3) than patients without AF (2008 to 2012 median BMS 33% to 25%, annual interquartile ratios range 2.0 to 1.8). In conclusion, among stent recipients, patients with AF are more likely to receive BMS than patients without AF but treatment varies across systems, suggesting a lack of consensus. Studies of stent choice and outcomes among patients with AF are needed to guide care decisions and optimize outcomes.