September 22nd, 2014
ACC Withdraws ‘Choosing Wisely’ Recommendation Against Revascularization of Nonculprit Lesions
Larry Husten, PHD
The American College of Cardiology said today that it was withdrawing one of its five recommendations in the “Choosing Wisely” campaign. In 2012 the ACC recommended that heart attack patients should have only their culprit artery unblocked. It said that patients and caregivers should question whether complete revascularization of all nonculprit lesions in heart attack patients should be performed.
The original recommendation was based on non-randomized studies suggesting that treating all significantly blocked vessels in heart attack patients could be harmful. “However,” the ACC now states, “over the last two years, new science has emerged showing potential improvements for some patients in their overall outcomes as a result of complete revascularization.”
Two recent randomized controlled trials have altered the field. The 2013 PRAMI trial and last month’s CvLPRIT trial offered evidence that stenting all arteries with large blockages improved the outcome of heart attack patients. But the studies, the ACC states, left many open questions “about the exact timing of the procedures; whether certain patients benefit versus others; whether FFR might guide decisions; and the role of patient complexity and hemodynamic stability.”
“Science is not static but rather constantly evolving,” said ACC President Patrick T. O’Gara, in a press release. He said current clinical guidelines and appropriate use criteria recommendations will also address the impact of the trials. The ACC said it plans to update its “Choosing Wisely” recommendations.
3 Responses to “ACC Withdraws ‘Choosing Wisely’ Recommendation Against Revascularization of Nonculprit Lesions”
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Choosing Wisely number 5 was a terrible choice by the ACC. For the Choising Wisely program to be effective for patients & physicians it needs to include only solidly settled clinical science.
The recommendation that non-culprit vessels be left unrevascularized in the setting of primary PCI without convincing data should have disqualified it for inclusion in the document.
The decision about risk & benefit of non-culprit revascularizarion was uncertain and matters such as this should be left to physician discretion until the science is more convincingly settled.
I think Choosing Wisely initative has been a wonderful health education program and going forward will be strengthened by removal of #5 and inclusion of only statements that have broad consensus and supportive data so that confidence can be restored in its underlying goals.
Taking off ad hoc PCI of non-culprit artery during STEMI from the list of 5 cardiac procedures to avoid as part of the Choosing Wisely campaign raises a few questions that merit consideration.
1. What is the quality and quantity of evidence required to put interventions on the Choosing Widely list? Based on the existing body of evidence, did ad hoc PCI of non culprit artery qualify to be put on the list?
2. What is the quality and quantity of evidence required to get off the Choosing Widely list? Does PRAMI and unpublished results from CvLPRIT (that have not yet passed peer review muster) provide the required evidence to justify this action?
3. What should be the ideal trial design to address this clinically important issue? Ad hoc PCI vs no PCI? Or Ad hoc PCI versus staged ischemia-driven PCI? Has this been addressed systematically in any trial to date? And what should be the relevant primary outcome of interest of such a trial?
4. Do you think ‘arbitrarily’ putting procedures on and taking them off the Choosing Widely list undermines the credibility of the process and detracts from the IOM goal of developing trustworthy guidelines?
5. Given all of this, do you think the ACC/AHA was correct in taking this action?
Would be interested in your thoughts.
The fifth item was not only unsupported by a good trial, but also ill-conceived from a Choosing Wisely standpoint , as this issue is far too complex and hypothetical to approach with patients.
If an item about coronary angiography and PCI is desirable, a COURGE -like statement suggesting balanced discussion of an initially noninvasive strategy for at least low risk angina or CAD.
Or, how about overuse of “advanced” lipid assays or even just multiple excessive lipid and LFT evaluations.
To be on the list, trial-based evidence is combined with cost-effectiveness on a population level. The revoked fifth item was poor in both arenas.
Popular image is of course key. Withdrawing is undesirable. Claiming that “science” motivated the change may be a reasonable public statement, without saying that the the original inclusion was weak. But it would have been better to “replace” the fifth with a new one, deriving renewed attention to the list and to this new well chosen item, and detracting questions about the mishap.