Appropriateness of Percutaneous Coronary Intervention Trends Show Significant Change in Management

Presented by Nihar R. Desai, MD, MPH et. al., “Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention – Findings From the NCDR-CathPCI Registry” assesses the impact of published Appropriate Use Criteria (AUC) for coronary stenting. The AUC were developed jointly by the Society for Cardiovascular Angiography and Interventions (SCAI) and five other cardiovascular societies in 2009 and updated in 2012. They provide advice to heart doctors about conditions where it is appropriate to use coronary stents, and conditions where it is inappropriate to routinely use coronary stents.

Using a large national registry of patients undergoing coronary stenting, researchers looked at patients who were stable. Between 2009 and 2014, the total percentage of PCI patients receiving coronary stents for clinical scenarios rated “inappropriate” fell from 3.6% to 1.8% — a 50% reduction.

The researchers also found that stable patients undergoing coronary stenting in 2014 had more severe symptoms, more intense medical therapy, and more abnormal stress tests. They concluded that cardiologists were trying more intense medical therapy, as recommended by current guidelines, before resorting to coronary stenting.

“These findings suggest the Appropriate Use Criteria have influenced doctors to adhere more closely to guidelines for medical therapy and more carefully identify patients who will really benefit from coronary stenting,” said SCAI President, James C. Blankenship, MD, MHCM, FSCAI. “SCAI has made a huge effort to help cardiologists make these difficult decisions by developing quality tools and apps for them. We are pleased that cardiologists are using these to improve the care they provide to patients.”

Blankenship continued, “This research also shows that four-fifths of coronary stenting procedures in the United States are performed for unstable patients, such as those having heart attacks. Almost all of these are deemed ‘appropriate’. Thus, patients with an ‘inappropriate’ rating in 2014 were only 1.8% of all patients receiving this procedure. Experts agree that for some patients in some situations, ‘inappropriate’ stenting is truly the right thing to do, and we hope that further research will determine if the current rate of 1.8% is excessive.”  

One problem with the current AUC is that they do not rate all situations where patients are treated with coronary stents, so their “appropriateness” was not rated in this study. Updated AUC will be released within a year that will allow almost all patients to be rated for appropriateness, and will replace the term “inappropriate” with “rarely appropriate”.

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