Sobrevida específica e fatores associados ao risco de reintervenção adicional por técnica alternativa entre pacientes submetidos a revascularização coronariana no SUS, Brasil

Abstract

The Cardiac Artery Bypass Grafting (CABG) and the Percutaneous Coronary Intervention (PCI) - invasive treatments for Coronary Artery Disease (CAD) - are among the most commonly performed procedures in the Unified Health System (SUS), with PCI growing the frequency of year-on-year. In the course of these patients’ treatment, reintervention may be necessary, with a clinical, social and financial potential impact. Additional reintervention by alternative technique is slightly studied. The objective was to describe and analyze specific survival and factors associated with the risk of additional reintervention by alternative technique among patients undergoing CABG and PCI in SUS, Brazil. Methods: Open cohort study, prospective, non-concurrent of patients undergoing CABG and PCI by SUS from 2004 to 2014. The source was the National Health Base, built by the deterministic-probabilistic relationship of data from the Outpatient Information Systems (SIA), Hospital (SIH) and Mortality (SIM) of SUS. The outcome of interest was the reintervention using an alternative technique to the first. The global survival was analyzed by the Kaplan-Meier method and the specific one by the analysis of the Cumulative Incidence Function (CIF). Sensitivity analysis verified possible bias in CIF of PCI´s group caused by staggered procedures. Factors associated with reintervention-free survival by alternative technique were analyzed using the Fine and Gray competitive risk regression model. The level of significance was 5%. Results: 123,405 patients were analyzed in the CABG group and 251,858 in the PCI group. The alternative technique was applied in 90.35% of the cases of the CABG group and 17.10% of the PCI group. In the CABG group the event or lower risk was a competitive event- reintervention by similar technique (p <0.001). CABG without Cardiopulmonary Bypass and the time-calendar increased the risk of reintervention by alternative technique (p <0.001). Alternative technique was the event of lower risk for the PCI group (p <0.001). PCI with stents and time-calendar decreased the risk (p <0.001). In the CABG group, living in the South and Midwest, vasculopathy, Chronic Kidney Disease (CKD), diabetes and treatment in a philanthropic institution increased the risk of reintervention by alternative technique. Increase in age group and male gender decreased risk. In the PCI group, male sex, living outside the Southeast region, diabetes and treatment in a philanthropic institution increased the risk of reintervention by alternative technique. Increased age range and presence of CKD decreased the risk. Conclusion: The CAD treatment by PCI was associated with a lower risk of reintervention by alternative technique as the first additional revascularization. The global risk of reintervention in both groups decreased over time, reflecting technological advances. The reintervention risk, in particular by alternative technique, should be considered on the health policies planning of cardiovascular care.

Keywords: Survival Analysis. Risk. Cardiac Artery Bypass Grafting. Percutaneous Coronary Intervention. Risk Groups. Prospective Studies.