February 8th, 2012
(In)Appropriate PCI: An (In)Appropriate Critique?
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:
- Acknowledging when PCI may be appropriate even without an improvement in symptoms;
- Incorporating fractional flow reserve (FFR) for identification of the culprit lesion; and
- Including bypass graft status in patients with previous CABG.
Nonetheless, some of the issues they raised were not addressed in the update, including:
- Lack of concordance between the AUC technical panel and the clinical cardiology community regarding PCI appropriateness designations;
- Overdependence on stress testing pre-PCI; and
- 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:
- 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
- Preprocedural stress testing should not be required in patients with class II angina.
Do you agree?