This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: j.jacc.2007.06.022v1 50/13/1223    most recent Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gerber, Y. Articles by Roger, V. L. Search for Related Content PubMed Articles by Gerber, Y. Articles by Roger, V. L.

CLINICAL RESEARCH: CORONARY REVASCULARIZATION

Coronary Revascularization in the Community

A Population-Based Study, 1990 to 2004

Yariv Gerber, PhD^_*,,, Charanjit S. Rihal, MD^_*, Thoralf M. Sundt, III, MD^_*, Jill M. Killian, BS, Susan A. Weston, MS, Terry M. Therneau, PhD and Véronique L. Roger, MD, MPH^_*,,_*

^_* Division of Cardiovascular Diseases
Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota
Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel

Manuscript received January 2, 2007; revised manuscript received May 22, 2007, accepted June 19, 2007.

^_* Reprint requests and correspondence: Dr. Véronique L. Roger, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. (Email: roger.veronique{at}mayo.edu).

	Abstract

Top Abstract Methods Results Discussion Conclusions References

 
Objectives: We sought to examine temporal trends in the utilization of coronary revascularization in a geographically defined population.

Background: Earlier reports on revascularization utilization focused on inpatient settings and did not distinguish incident from recurrent procedures. Furthermore, little is known on age- and gender-specific trends. Finally, longitudinal data on the utilization and results of coronary angiography as explanatory factors for the changing revascularization practice are lacking.

Methods: Data integrating diagnostic and therapeutic coronary procedures performed in Olmsted County (Minnesota) between 1990 and 2004 were analyzed. Standardized rates were calculated applying the direct method and temporal trends compared using Poisson regression models.

Results: Revascularization utilization increased by 24% during the study (95% confidence interval [CI] 5% to 46%), but the trends diverged by procedure type, with a sustained increase (69%, 95% CI 43% to 101%) for percutaneous coronary interventions (PCI) contrasting with a stabilization, then decline (–33%, 95% CI –16% to –47%) for coronary artery bypass grafting (CABG). For PCI, although the use increased in all categories, greater increases were noted in the elderly, in women, and for recurrent procedures. No such patterns were detected for CABG. Angiography use remained stable, and the rate of 3-vessel and/or left main disease declined (–22%, 95% CI –8% to –33%).

Conclusions: Over the 15-year period, revascularization increased in the community with a large increase in PCI partially offset by a decrease in CABG. More PCIs are performed in women and the elderly and for recurrent disease. These changes occurred within the context of a decline in multivessel disease and thus likely reflect the natural history of coronary artery disease.

Abbreviations and Acronyms   CABG = coronary artery bypass grafting   CAD = coronary artery disease   CI = confidence interval   LM = left main   PCI = percutaneous coronary intervention   RR = rate ratio

Moreover, although earlier studies have documented age and gender differences in utilization of revascularization procedures (14–18), conflicting evidence has been reported regarding age- and gender-specific trends (2,4,8,19–21), which might be related to the selected nature of the populations studied (e.g., Medicare beneficiaries or patients with acute myocardial infarction). Furthermore, because the ability to distinguish between incident (i.e., first-ever) and recurrent procedures, which generally requires person-based data, was lacking in most studies, it is uncertain whether the proportion of incident versus recurrent procedures has changed over time (7,21).

Finally, because the selection between CABG and PCI is largely influenced by anatomic coronary artery disease (CAD) (5,22–24), it is important to interpret revascularization trends in light of temporal changes in the extent and severity of angiographic CAD.

To address these gaps in knowledge, we studied trends in revascularization utilization in Olmsted County, Minnesota, between 1990 and 2004. Specifically, we assessed variations according to procedure type, age, gender, and incident status and evaluated trends in the use and results of coronary angiography as contributing factors to the variations seen in coronary revascularization.

	Methods

Top Abstract Methods Results Discussion Conclusions References

 
Study setting.   The population of Olmsted County is served by a largely unified medical care system that has accumulated comprehensive clinical records over an extensive period (25,26). Olmsted County (2000 census population 124,277) is 144 km southeast of Minneapolis and St. Paul, with approximately 70% of its population residing in Rochester, the centrally located county seat. In 2000, about 90% of all residents were white and 11% were aged 65 years or more (27). The Olmsted County population is largely middle class, with 91% of adults having graduated from high school and only 2.4% uninsured. With the exception of a higher proportion being employed in the health care industry, the population characteristics are similar to those of white Americans nationally.

Epidemiologic research in Olmsted County is feasible because the city and county are relatively isolated from other urban centers, and nearly all medical care is delivered to local residents by a handful of providers. The Mayo Medical Center and the Olmsted Medical Group and its affiliated Olmsted Community Hospital provide comprehensive care for the region in every clinical discipline. The epidemiologic potential of this situation is enhanced by the fact that each provider uses a unit medical record system, whereby all data collected for an individual are assembled in 1 place. The unit records of each provider in the county are available for use. These medical records are easily retrievable because the Mayo Clinic has maintained since the early 1900s extensive indexes based on clinical and histologic diagnoses and surgical and billable procedures. The Rochester Epidemiology Project (25,26) has developed a similar index for the records of other providers of medical care to local residents. This indexing system includes death certificates for Olmsted County residents. The result is the linkage of medical records from essentially all sources of medical care available to and used by the Olmsted County population. All aspects of the present study were approved by the appropriate institutional review boards.

Coronary procedures.   Since 1955, the Mayo Clinic has maintained an index of surgical procedures, which can be queried electronically. This allowed identifying all patients who underwent CABG between 1990 and 2004. Similarly, registries of all coronary angiography procedures, diagnostic and therapeutic, have been maintained since 1979. Because the Mayo Clinic is the sole provider of coronary angiography, PCI, and CABG surgery in Olmsted County, this case finding approach resulted in the complete ascertainment of all revascularization procedures performed in the county.

We defined revascularization as CABG or PCI, with or without stent insertion. Incident status was defined as revascularization with no prior CABG or PCI.

Significant angiographic CAD was defined as 75% stenosis or greater of the left anterior descending, left circumflex, or right coronary artery or 50% stenosis or greater of the left main (LM) coronary artery (28). Three mutually exclusive disease categories were created for analytic purposes: 1) negative (no significant stenosis); 2) positive (1- or 2-vessel disease not involving the LM artery); and 3) severe (3-vessel or LM CAD). Sensitivity analyses were conducted using the Coronary Artery Surgery Study extent and severity scores, which evaluate the global burden of CAD in the entire coronary tree (29).

Statistical analyses.   Age-, gender-, and year-specific utilization rates were calculated for each procedure. The denominators were determined by Olmsted County population census data for 1990 and 2000, with linear interpolation for the intercensal years and extrapolation after 2000 (30). These rates were directly standardized to the age and gender distributions of the 2000 U.S. population using a lower cutoff for age of 25 years.

Poisson regression models were used to assess temporal trends in procedure utilization overall and by selected categories using the SAS procedure GENMOD (SAS Institute Inc., Cary, North Carolina). Specific counts for each calendar year, age (using midpoints of 10-year intervals), gender, and incident/recurrent category were used as the unit of observation. Rate ratios (RR) and 95% confidence intervals (CI) of procedure utilization in different time periods (using tertiles defined as 1990 to 1994 [reference], 1995 to 1999, and 2000 to 2004) were estimated. Percentage change for the entire study period was also estimated. Comparisons of temporal trends across specific groups and categories were performed by including the 2-way interaction term of each variable with year-after adjustment for all main effects. Then 3-way interactions were assessed in models that included the corresponding main effects and 2-way interactions.

Model goodness-of-fit was assessed by examining the deviance statistic, and corrections for overdispersion were performed (SAS dscale option). A p value of 0.05 was selected for the threshold of statistical significance except when testing for interactions, where p values up to 0.10 were accepted.

	Results

Top Abstract Methods Results Discussion Conclusions References

 
Over the 15 years of the study, 4,681 coronary revascularizations were performed in 3,525 individuals. This includes 3,139 PCIs (31% in women) and 1,542 CABGs (26% in women). One-fourth of both PCIs and CABGs were performed in individuals age 75 years or more.

Use of CABG versus PCI.   There was an upward trend in the use of revascularization, with a rapid increase throughout the 1990s followed by a relative stabilization in the initial years of the new millennium (Fig. 1). Accordingly, the overall utilization rates (per 100,000 persons) were 343 in 1990 to 1994, 420 in 1995 to 1999, and 453 in 2000 to 2004. Compared with the reference period (1990 to 1994), the age- and gender-adjusted RR in the years 1995 to 1999 and 2000 to 2004 were 1.15 (95% CI 1.01 to 1.31) and 1.21 (95% CI 1.07 to 1.37), respectively (Table 1). This equates to a total increase of 24% (95% CI 5% to 46%) in coronary revascularization between 1990 and 2004.

View larger version (25K): [in this window] [in a new window] [Download PPT slide]   Figure 1 Trends in Coronary Revascularization in Olmsted County, Minnesota, 1990 to 2004 Yearly rates (95% confidence intervals [CIs]), per 100,000 persons, have been standardized by the direct method to the age and gender distribution of the U.S. population in 2000. CABG = coronary artery bypass graft; PCI = percutaneous coronary intervention.

Of all PCIs undertaken over the study period, 1,134 (36%) were balloon angioplasties and 2,005 (64%) involved stent placement. The percentage of stent insertion as part of PCI increased from 31% (95% CI 24% to 38%) in 1995 to 94% (95% CI 91% to 96%) in 2004. In 2004, among PCIs where a stent was placed, 86% (95% CI 81% to 89%) were drug-eluting stents. For CABG, the percentage of procedures performed off-pump increased from 4.2% (95% CI 2.7% to 6.2%) in 1995 to 1999 to 7.2% (95% CI 5.1% to 9.8%) in 2000 to 2004. No association between age and off-pump CABG was detected.

Trends by age and gender.   Age- and gender-specific trends, by procedure type, are shown in Table 1. For PCI, although increases occurred in all demographic groups, substantial variations in the trends were noticed, because the magnitude of the increase was greater in the elderly (p < 0.0001 for the year-by-age interaction) and in women (p = 0.07 for the year-by-gender interaction). Accordingly, the RR in the final versus initial 5 years of the study was 2.67 (95% CI 2.01 to 3.55) in persons age 75 years or more compared with 1.40 (95% CI 0.98 to 2.01) in persons <75 years old and 1.71 (95% CI 1.38 to 2.11) in women compared with 1.43 (95% CI 1.21 to 1.69) in men (age-adjusted). However, in absolute terms, the respective increase in rate (per 100,000 persons) was larger in men (from 298 to 470) than in women (from 117 to 211). For CABG, no significant age or gender interactions were detected. Yet, unlike younger individuals for whom a steep decline in CABG use was noted, no decrease over time was shown in persons aged 75 years or more.

Trends by incident status.   As shown in Fig 2, trends in incident versus recurrent revascularization rates differed between PCI and CABG (p < 0.0001 for the year-by-type-by-incident status interaction). For PCI, the age- and gender-adjusted rates of recurrent procedures rose steeply, whereas a more modest increase occurred in incident procedures. Indeed, the rates (per 100,000 persons) increased from 74 in 1990 to 1994 to 147 in 2000 to 2004 for recurrent PCI, and from 164 to 215, respectively, for incident PCI. Accordingly, the RR in 2000 to 2004 versus 1990 to 1994 was 1.93 (95% CI 1.59 to 2.34) for recurrent procedures compared with 1.31 (95% CI 1.15 to 1.50) for incident procedures (p = 0.001 for the interaction). In contrast, no year-by-incident status interaction was detected for CABG (respective RR 0.67 [95% CI 0.54 to 0.84] and 0.81 [95% CI 0.69 to 0.96]; p = 0.32 for the interaction).

View larger version (79K): [in this window] [in a new window] [Download PPT slide]   Figure 2 Trends in Coronary Revascularization Partitioned Into Procedure Types and Incident Status Categories Rates (per 100,000 persons) were standardized by the direct method to the age and gender distribution of the U.S. 2000 population and are shown at 5-year intervals. Abbreviations as in Figure 1.

View larger version (19K): [in this window] [in a new window] [Download PPT slide]   Figure 3 Trends in Angiography Use and Results in Olmsted County, Minnesota, 1990 to 2004 Yearly rates (per 100,000 persons) are shown on a logarithmic scale and were standardized by the direct method to the age and gender distribution of the U.S. population in 2000. CAD = coronary artery disease; LM = left main coronary artery.

	Discussion

Top Abstract Methods Results Discussion Conclusions References

 
Summary of findings.   In Olmsted County from 1990 to 2004, a 69% increase in PCI accompanied by a 33% decrease in CABG resulted in an increase of 24% in total revascularization. For PCI, although increases were noted in all categories examined, variations in the magnitude of the increase were detected. Utilization among the elderly increased more steeply than among younger persons; a greater increase was noted in women compared with men; and repeat procedures rather than incident ones contributed mostly to the overall trend. Trends in CABG were less heterogeneous, yet, unlike other groups or categories, no decrease was shown in the elderly. Although the use of coronary angiography did not change significantly over the study period, the rate of severe disease declined by 22%.

Trends by revascularization type.   Although an increase in the use of PCI and a decrease in CABG have been widely reported (1–10), some, but not all, of these reports have further noticed a stabilization in PCI and total revascularization in the most recent years (3,5,6,8,10). However, those studies were carried out in inpatient settings and their results should be interpreted with caution, because they may not encompass all revascularization practices (1,11–13).

The present study incorporates data from a geographically defined community over a long period of time, including recent years, thereby addressing this gap in knowledge. The use of PCI increased steadily over time along with a decline in CABG, resulting in a net moderate increase in total revascularization. Although the driving forces of these diverging trends remain to be defined, several key factors have been the focus of this study, as detailed subsequently.

Age and gender effect.   Because the burden of cardiovascular disease has shifted toward elderly persons and women (31–33), age and gender are likely to play a crucial role in any current cardiovascular procedural trend. Moreover, because disparities in the use of coronary revascularization for women and elderly persons have been documented in earlier studies (14–18), it is essential to monitor temporal trends in these specific groups.

Several studies have found a progressive increase in utilization among the elderly of both CABG (2,7–10,21) and PCI (1–3), whereas trends by gender have been less consistent with some (2,19), but not all (3,4,8,21), studies reporting a greater increase in women relative to men. However, many of the studies were carried out in selected populations, such as Medicare beneficiaries, patients from a single institution or persons after myocardial infarction.

The present study thus provides important new knowledge on this topic by demonstrating that, in the community, an increasing proportion of PCI, more than of CABG, is performed in elderly persons and women. These findings are likely due to a combination of several factors, including demographic changes occurring in the population (31,33), gender differences in CAD manifestation (34,35), greater tendency and awareness among health care providers of the preexisting treatment differences by age and gender (19,36), and perception of the upper age limit for CABG (7). Note that the latter perception may differ by type of CABG, because promising results have been reported for elderly patients undergoing off-pump CABG (37).

Incident and recurrent procedures.   Trends in incident and recurrent procedures are likely driven by different mechanisms. Incident procedures are affected by trends in incidence and prevalence of CAD, changing clinical indications for revascularization, and the effectiveness of alternative treatments. Recurrent procedures are determined by the prevalence and type of previous revascularization and by technical innovations that reduce the likelihood of restenosis (3).

Little is known about trends according to incident status. Although some studies have suggested a decreasing rate of recurrent procedures (3,21), others have reported the opposite (7,38). However, none of those studies was conducted in a defined community, so the reported trends are challenging to interpret in terms of their implications in the practice of cardiology.

The present study indicates that the sizable increase in recurrent procedures was the dominant force for the upward trend in PCI use, whereas incident procedures have increased to a lesser extent. In contrast, a comparable decrease in CABG rates was shown between incident and recurrent procedures.

Angiography use and results.   Although CABG and PCI are alternative methods of coronary revascularization, CABG surgery is traditionally seen as an approach indicated mainly for extensive CAD. However, as experience and technology have evolved, through simple balloon angioplasty, to bare metal coronary stents, and then drug-eluting stents, PCI has been increasingly used for coronary anatomy of increasing complexity (24). Therefore, the use and results of angiography are key elements to consider in interpreting revascularization trends.

Two recent studies, one from the U.S. and the other from Canada, have reported an increasing use over time of cardiac catheterization (2,4). However, in the present study, no change in the use of angiography was noted. A possible explanation for these conflicting results might be the differences between the study populations. Whereas Lucas et al. (4) studied Medicare patients (usually age 65 years or more), Alter et al. (2) examined trends among Ontario residents (with no age limit). Because the age-specific procedure rates in the Canadian study lagged far behind those of the American study, and the latter was limited to elderly persons, the applicability of these findings to U.S. practice is unclear. These considerations notwithstanding, the stable rates of coronary angiography noted in Olmsted County during the study period facilitate the interpretation of angiographic findings and ensuing revascularization practice.

A single study suggested an increase in single-vessel disease and a decrease in 3-vessel disease (21). The present study extends those findings by indicating that a decrease in severe CAD, defined as LM and/or 3-vessel disease, occurred along with a substantial increase in angiographic findings not meeting criteria for significant disease, suggesting a decreasing threshold for undertaking coronary angiography. However, the temporal decline in CAD severity observed in our study need not be influenced by the more liberal approach to angiography, because each of the angiographic categories was assessed individually (i.e., not only proportionally to other categories).

Although CABG is still indicated chiefly for multivessel and/or LM disease (5,39), our findings on revascularization trends likely reflect, at least in part, changes in the severity of angiographic CAD. Temporal changes in the use of PCI for more complex disease and a decreasing threshold for performing revascularization may play complementary roles.

Study limitations.   Our findings pertain to a single community, and the extent to which they represent other populations, given regional variation across the U.S. (40) and the limited ethnic diversity of this community (27), may be questioned. In addition, different staffing patterns could have altered the results. Still, utilization rates among Medicare beneficiaries in Rochester do not exceed the national average in any of the procedures studied (41), and mortality rates from cardiovascular diseases in Olmsted County are commensurate with national rates (31). Because these data are restricted to local residents, the study is not subject to referral bias (42). Finally, because the main objective of this study was to evaluate specific trends in the practice of coronary revascularization by procedure type, demographic groups, and incident status, there is no plausible reason to believe that the observed patterns differ materially from other settings. This is particularly true because this study focuses on well established widely available techniques.

Although no study could be generalizable to the entire U.S. population, the value of Olmsted County studies lies in the ability to measure in 1 population the comprehensive utilization of revascularizations and interpret the large changes observed in light of the presence and severity of angiographic CAD, which were lacking up to this point. It is noteworthy that our data do not include referral indications or clinical indicators such as ejection fraction or diabetes status; therefore, inferences about appropriateness of care cannot be made from this study.

	Conclusions

Top Abstract Methods Results Discussion Conclusions References

 
In Olmsted County over the 15-year period, a moderate increase in coronary revascularization was observed. This was primarily related to a rapid increase in PCI incompletely offset by a concomitant decline in CABG. Trends in PCI varied between demographic groups, with greater increases in elderly persons and women. Furthermore, recurrent procedures rather than incident procedures were the major driver of the increase in PCI. A decrease in the extent and severity of CAD occurred during this period and likely played a key role in the changing face of coronary revascularization.

	Footnotes

 
Supported by a postdoctoral fellowship award from the American Heart Association, Greater Midwest Affiliate (0525753Z), and grants from the Public Health Service and the National Institutes of Health (AR30582, R01 HL 59205, and R01 HL 72435). Dr. Roger is an Established Investigator of the American Heart Association.

	References

Top Abstract Methods Results Discussion Conclusions References

 

1. Bernstein AB, Hing E, Moss AJ, Allen KF, Siller AB, Tiggle RB. Health Care in America: Trends in Utilization. Hyattsville, MD: National Center for Health Statistics, 2003.
2. Alter DA, Stukel TA, Newman A. Proliferation of cardiac technology in Canada: a challenge to the sustainability of Medicare Circulation 2006;113:380-387.[Abstract/Free Full Text]
3. Hobbs MS, McCaul KA, Knuiman MW, Rankin JM, Gilfillan I. Trends in coronary artery revascularisation procedures in Western Australia, 1980–2001 Heart 2004;90:1036-1041.[Abstract/Free Full Text]
4. Lucas FL, DeLorenzo MA, Siewers AE, Wennberg DE. Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993–2001 Circulation 2006;113:374-379.[Abstract/Free Full Text]
5. Mack MJ, Brown PP, Kugelmass AD, et al. Current status and outcomes of coronary revascularization 1999 to 2002: 148,396 surgical and percutaneous procedures Ann Thorac Surg 2004;77:761-766.[Abstract/Free Full Text]
6. Maynard C, Sales AE. Changes in the use of coronary artery revascularization procedures in the Department of Veterans Affairs, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample, 1991–1999 BMC Health Serv Res 2003;3:12.[CrossRef][Medline]
7. Northrup 3rd WF, Emery RW, Nicoloff DM, Lillehei TJ, Holter AR, Blake DP. Opposite trends in coronary artery and valve surgery in a large multisurgeon practice, 1979–1999 Ann Thorac Surg 2004;77:488-495.[Abstract/Free Full Text]
8. Pell J, Slack R. The Scottish Coronary Revascularisation Register: Time Trends 1997–2003Glasgow: Greater Glasgow National Health Service Board; 2004.
9. Sistino JJ. Epidemiology of cardiovascular disease in the last decade: treatment options and implications for perfusion in the 21st century Perfusion 2003;18:73-77.[Abstract/Free Full Text]
10. Ulrich MR, Brock DM, Ziskind AA. Analysis of trends in coronary artery bypass grafting and percutaneous coronary intervention rates in Washington state from 1987 to 2001 Am J Cardiol 2003;92:836-839.[CrossRef][ISI][Medline]
11. Bottner RK, Blankenship JC, Klein LW. Current usage and attitudes among interventional cardiologists regarding the performance of percutaneous coronary intervention (PCI) in the outpatient setting Catheter Cardiovasc Interv 2005;66:455-461.[CrossRef][Medline]
12. Kozak LJ, Hall MJ, Pokras R, Lawrence L. Ambulatory surgery in the United States, 1994. Adv Data 1997;283:1–15.
13. Slagboom T, Kiemeneij F, Laarman GJ, van der Wieken R, Odekerken D. Actual outpatient PTCA: results of the OUTCLAS pilot study Catheter Cardiovasc Interv 2001;53:204-208.[CrossRef][ISI][Medline]
14. Ayanian JZ, Epstein AM. Differences in the use of procedures between women and men hospitalized for coronary heart disease N Engl J Med 1991;325:221-225.[Abstract]
15. Bearden D, Allman R, McDonald R, Miller S, Pressel S, Petrovitch H, SHEP Cooperative Research Group Age, race, and gender variation in the utilization of coronary artery bypass surgery and angioplasty in SHEPSystolic Hypertension in the Elderly Program. J Am Geriatr Soc 1994;42:1143-1149.[ISI][Medline]
16. Giles WH, Anda RF, Casper ML, Escobedo LG, Taylor HA. Race and sex differences in rates of invasive cardiac procedures in U.S. hospitalsData from the National Hospital Discharge Survey. Arch Intern Med 1995;155:318-324.[Abstract]
17. Roger VL, Farkouh ME, Weston SA, et al. Sex differences in evaluation and outcome of unstable angina JAMA 2000;283:646-652.[Abstract/Free Full Text]
18. Steingart RM, Packer M, Hamm P, et al. , Survival and Ventricular Enlargement InvestigatorsSex differences in the management of coronary artery disease. N Engl J Med 1991;325:226-230.[Abstract]
19. Harrold LR, Esteban J, Lessard D, et al. Narrowing gender differences in procedure use for acute myocardial infarction: insights from the Worcester heart attack study J Gen Intern Med 2003;18:423-431.[CrossRef][ISI][Medline]
20. Jha AK, Fisher ES, Li Z, Orav EJ, Epstein AM. Racial trends in the use of major procedures among the elderly N Engl J Med 2005;353:683-691.[Abstract/Free Full Text]
21. Plume SK, O'Connor GT, Olmstead EM, Northern New England Cardiovascular Disease Study Group As originally published in 1994: changes in patients undergoing coronary artery bypass grafting: 1987–1990Updated in 2000. Ann Thorac Surg 2001;72:314-315.[Abstract/Free Full Text]
22. Hannan EL, Racz MJ, Walford G, et al. Long-term outcomes of coronary-artery bypass grafting versus stent implantation N Engl J Med 2005;352:2174-2183.[Abstract/Free Full Text]
23. Malenka DJ, Leavitt BJ, Hearne MJ, et al. Comparing long-term survival of patients with multivessel coronary disease after CABG or PCI: analysis of BARI-like patients in northern New England Circulation 2005;112:I371-I376.[ISI][Medline]
24. Reul RM. Will drug-eluting stents replace coronary artery bypass surgery? Tex Heart Inst J 2005;32:323-330.[ISI][Medline]
25. Kurland LT, Elveback LR, Nobrega FT. Population studies in Rochester and Olmsted County, Minnesota, 1900–1968In: Kessler IT, Levin ML, editors. The Community as an Epidemiologic Laboratory; a Casebook of Community Studies. Baltimore, MD: Johns Hopkins Press; 1970. pp. 47-70.
26. Melton 3rd LJ. History of the Rochester Epidemiology Project Mayo Clin Proc 1996;71:266-274.[ISI][Medline]
27. League of Minnesota Cities. Census 2000 Update: Expanded Minnesota Profiles. Available at: http://www.lmnc.org/census/census.cfm. Accessed September 26, 2006.
28. Kennedy JW, Kaiser GC, Fisher LD, et al. Clinical and angiographic predictors of operative mortality from the collaborative study in coronary artery surgery (CASS) Circulation 1981;63:793-802.[Abstract/Free Full Text]
29. Vlietstra RE, Kronmal RA, Frye RL, Seth AK, Tristani FE, Killip 3rd T. Factors affecting the extent and severity of coronary artery disease in patients enrolled in the coronary artery surgery study Arteriosclerosis 1982;2:208-215.[Abstract/Free Full Text]
30. Bergstrahl EJ, Offord KP, Chu C-P, Beard CM, O'Fallon WM. Calculating Incidence, Prevalence, and Mortality Rates for Olmsted County, Minnesota Residents: an Update. Technical Report Series No. 49. Rochester, MN: Section of Biostatistics, Mayo Clinic, 1992.
31. Gerber Y, Jacobsen SJ, Frye RL, Weston SA, Killian JM, Roger VL. Secular trends in deaths from cardiovascular diseases: a 25-year community study Circulation 2006;113:2285-2292.[Abstract/Free Full Text]
32. Gerber Y, Weston SA, Killian JM, Jacobsen SJ, Roger VL. Sex and classic risk factors after myocardial infarction: a community study Am Heart J 2006;152:461-468.[CrossRef][ISI][Medline]
33. Roger VL, Jacobsen SJ, Weston SA, et al. Trends in the incidence and survival of patients with hospitalized myocardial infarction, Olmsted County, Minnesota, 1979 to 1994 Ann Intern Med 2002;136:341-348.[Abstract/Free Full Text]
34. Krumholz HM, Douglas PS, Lauer MS, Pasternak RC. Selection of patients for coronary angiography and coronary revascularization early after myocardial infarction: is there evidence for a gender bias? Ann Intern Med 1992;116:785-790.[ISI][Medline]
35. Miller TD, Roger VL, Hodge DO, Hopfenspirger MR, Bailey KR, Gibbons RJ. Gender differences and temporal trends in clinical characteristics, stress test results and use of invasive procedures in patients undergoing evaluation for coronary artery disease J Am Coll Cardiol 2001;38:690-697.[Abstract/Free Full Text]
36. Malenka DJ, Wennberg DE, Quinton HA, et al. Gender-related changes in the practice and outcomes of percutaneous coronary interventions in Northern New England from 1994 to 1999 J Am Coll Cardiol 2002;40:2092-2101.[Abstract/Free Full Text]
37. Beauford RB, Goldstein DJ, Sardari FF, et al. Multivessel off-pump revascularization in octogenarians: early and midterm outcomes Ann Thorac Surg 2003;76:12-17.[Abstract/Free Full Text]
38. Yau TM, Borger MA, Weisel RD, Ivanov J. The changing pattern of reoperative coronary surgery: trends in 1230 consecutive reoperations J Thorac Cardiovasc Surg 2000;120:156-163.[Abstract/Free Full Text]
39. Kappetein AP, Dawkins KD, Mohr FW, et al. Current percutaneous coronary intervention and coronary artery bypass grafting practices for three-vessel and left main coronary artery diseaseInsights from the SYNTAX run-in phase. Eur J Cardiothorac Surg 2006;29:486-491.[Abstract/Free Full Text]
40. Hannan EL, Wu C, Chassin MR. Differences in per capita rates of revascularization and in choice of revascularization procedure for eleven states BMC Health Serv Res 2006;6:35.[CrossRef][Medline]
41. The Dartmouth Atlas of Health Care. Available at: http://www.dartmouthatlas.org/index.shtm. Accessed September 26, 2006.
42. Melton 3rd LJ. Selection bias in the referral of patients and the natural history of surgical conditions Mayo Clin Proc 1985;60:880-885.[ISI][Medline]

This article has been cited by other articles:

				S. S. Brar, G. Syros, and G. Dangas Multivessel Disease: Percutaneous Coronary Intervention for Classic Coronary Artery Bypass Grafting Indications Angiology, August 1, 2008; 59(2_suppl): 83S - 88S. [Abstract] [PDF]

				R. F. Wilson and G. Raveendran What's good for the gander is now good for the goose. J. Am. Coll. Cardiol., June 17, 2008; 51(24): 2321 - 2322. [Full Text] [PDF]

This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: j.jacc.2007.06.022v1 50/13/1223    most recent Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gerber, Y. Articles by Roger, V. L. Search for Related Content PubMed Articles by Gerber, Y. Articles by Roger, V. L.