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CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

July 7th, 2011

NCDR Report on PCI Appropriateness: A Slap on the Back…or a Slap in the Face?

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According to an analysis of data from the National Cardiovascular Data Registry (NCDR), nearly all (98.6%) acute PCIs (i.e., those done for STEMI, NSTEMI, and unstable angina) were classified as appropriate. For nonacute indications, however, only 50% were classified as appropriate; 38% were of uncertain appropriateness, and 12% were deemed inappropriate.

Dig under the hood and what do you find?

1. Appropriateness could not be determined in 17% of the > 600,000 PCIs in the NCDR because of inadequate data.  If these represented low-risk patients, then the rate of inappropriate PCIs in the nonacute setting would be 21%, not 12%.

2. Substantial variation in the proportion of inappropriate PCIs in nonacute settings was noted among hospitals, ranging from 0% to 55%.

3.  Of the patients undergoing an inappropriate PCI in the nonacute setting, 99% were asymptomatic or only mildly symptomatic, 72% had low-risk ischemia on noninvasive stress testing, 94% did not have coronary anatomic findings that were judged to be high risk, and 96% were treated with suboptimal antianginal therapy.

4. Although the authors state that it is “unlikely that hospitals inflated their rates of appropriate PCI by reporting more severe symptoms and stress test (results),” recent reports suggest otherwise.  Physicians may exaggerate symptom and lesion severity in subjects undergoing unnecessary PCIs, whereas the hospital provides no oversight or turns a blind eye because of the reimbursement involved.

4.  Of individuals who allegedly underwent appropriate nonacute PCI, 12% had no or minimal symptoms, 48% did not have high-risk features on noninvasive evaluation  of ischemia, and 22% were on no antianginal medications (with another 39% on only one medication).  How are these procedures appropriate?

Is this report a slap on the back…. or a slap in the face? Before answering, you may want to read Larry Husten’s take on the ACC President’s response.

Do you really believe that 98.6% of the PCIs performed for MI or unstable angina are truly appropriate?

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2 Responses to “NCDR Report on PCI Appropriateness: A Slap on the Back…or a Slap in the Face?”

  1. Ml Chawla, MBBS, MD ( Medicine) DM ( cardiology) says:
    July 12, 2011 at 7:47 am

    No, i do not.

  2. Brett Forge, MB BS FRACP says:
    July 19, 2011 at 12:21 am

    First it should be stated that a registry is only reliable if the data is independantly audited. Cardiologists know the indications so can easily refine their notes to make sure they confirm. I’ve seen many patients booked for ‘unstable angina’ when the patient has not had any angina for weeks and when they have a good exercise reserve on stress testing.

    Secondly I question the guidelines for NSTEMI. There is only 1 trial for routine PCI vs selective PCI in STEMI that has been performed in patients on acceptable current medical treatment. That is the ICTUS trial. This showed no benefit of routine over selective PCI. Meta analysis of previous trials showed no reduction in mortality and a 23% reduction in non-fatal AMI. These (selectively treated) patients did not receive clopidogrel or high dose statins in control groups. One would estimate that these treatments would eliminate the advantage (which indeed was seen in ICTUS). As well as that these trials included in their methodology a higher threshold for recurrent AMI for the PCI patients than the selectively treated patients. This is statistical nonsense and places the concept of a benefit as unreliable.
    If one accepts this then probably 40-50% of the ACS patients were inappropriate as well.

    Competing interests pertaining specifically to this post, comment, or both:
    nil