CardioExchange Archive

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.

February 8th, 2012

(In)Appropriate PCI: An (In)Appropriate Critique?

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According to a recently published study by Chan and colleagues, only 50% of the PCIs performed for nonacute indications were classified as appropriate, according to appropriate use criteria (AUC); 38% were “uncertain,” and 12% were inappropriate.

In a new expedited publication, Marso and colleagues  retort by expressing concerns with the “current” PCI AUC (see also our CardioExchange news coverage here).  However, the AUC document they critique is the 2009 version and not the current 2012 updated version, which addresses many of their concerns, including:

  1. Acknowledging when PCI may be appropriate even without an improvement in symptoms;
  2. Incorporating fractional flow reserve (FFR) for identification of the culprit lesion; and
  3. Including bypass graft status in patients with previous CABG.

Nonetheless, some of the issues they raised were not addressed in the update, including:

  1. Lack of concordance between the AUC technical panel and the clinical cardiology community regarding PCI appropriateness designations;
  2. Overdependence on stress testing pre-PCI; and
  3. Reliability of the National Cardiovascular Data Registry (NCDR) for obtaining necessary data with which to assess PCI appropriateness.

Two recommendations of Marso and colleagues are quite controversial and deserve vetting, and we’d like to hear your opinion.  The authors recommend that:

  1. PCI classification should be changed from inappropriate to uncertain in patients with Canadian Cardiovascular Society class I or II angina while taking 0 or 1 antianginal medication who have 1- or 2-vessel CAD without involvement of the proximal LAD and low-risk findings on noninvasive testing; and
  2. Preprocedural stress testing should not be required in patients with class II angina.

Do you agree?

 

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4 Responses to “(In)Appropriate PCI: An (In)Appropriate Critique?”

  1. Charles Roeth, MD says:
    February 9, 2012 at 2:52 pm

    Agree wholeheartedly as the oculostenotic reflex has not been shown tyo be beneficial

  2. Joel Wolkowicz, MDCM says:
    February 11, 2012 at 2:40 pm

    I disagree with Marso. There is no data to support his proposals. He wants to continue the practice of PCI as first line therapy for low risk patients who haven’t received adequate medical therapy. This increases cost, doesn’t improve outcomes, and increases the impulse to take patients with chest pain of uncertain etiology (as in fact many of these patients are) and pass them through the revolving door of chest pain to ER to Cath lab to home to chest pain to ER etc. Some of these patients would do much better with a thinking doctor rather than multiple stents, dual anti platelet therapy, and the label of being a “cardiac patient”. Ascertaining that symptoms are due to coronary ischemia, and that they don’t respond adequately to medical therapy does not remove the option of PCI in the future.

    In a zero sum game, we need to use our money wisely. Otherwise the politicians will tell us what to do.

    Competing interests pertaining specifically to this post, comment, or both:
    None

  3. Matthew Carr, MD says:
    February 15, 2012 at 12:43 am

    I am not comfortable with the whole idea of stress testing as the gold standard to decide about revasc. In our pracice I see at least 20%to 30% of stress tested patients where the results are just flat out wrong. How can this be the standard for revasc if iscchamia is quite often misrecognized? Again with the latest stents avaiable how can you ask the avid skier or biker to put up with betablockers (100 to 200 m oer day) or other frankly disabling medications when we have this treatment available. Oh I forgot, these patients never even make it into the “randomized” studies, they simply refuse to partipate. The selection bias in these studies is enormous in my opinion. I do think it reasonable that lesions be severe and even use ffr if borderline I do agree that when the symptoms do not correlate well with he disease, the results of angioplasty are frquently unclear to the pt and the docotor.

    Competing interests pertaining specifically to this post, comment, or both:
    none

  4. Mario Maiese, DO says:
    February 16, 2012 at 11:29 am

    I totally agree with Joel and couldn’t have said it better.

    Competing interests pertaining specifically to this post, comment, or both:
    none