Appropriateness of Percutaneous Coronary Intervention

Study Questions:

What is the appropriateness of percutaneous coronary intervention (PCI) in contemporary practice?

Methods:

The authors assessed the appropriateness of PCI among patients undergoing PCI between July 1, 2009, and September 30, 2010, at 1,091 hospitals enrolled in the NCDR®. Using the appropriate use criteria for coronary revascularization, all procedures were classified as appropriate, inappropriate, or uncertain. Analysis was stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non–ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication.

Results:

The study cohort was comprised of 500,154 procedures, of which 355,417 (71.1%) were for acute indications. The overall use of inappropriate PCI was low and mostly restricted to nonacute indications. Among patients with acute indication for PCI, 98.6% were classified as appropriate, 0.3% as uncertain, and 1.1% as inappropriate. For nonacute indications, 50.4% were classified as appropriate, 38.0% as uncertain, and 11.6% (n = 16,838) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), or suboptimal (≤1 medication) antianginal therapy (95.8%). There was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%-16.7%).

Conclusions:

Almost all of the PCIs performed in the United States for acute reasons were appropriate, whereas approximately 10-12% of those performed for nonacute reasons were classified as inappropriate.

Perspective:

The study suggests that the number of patients who undergo inappropriate PCI in the United States is approximately 4.14%, and most of these patients undergo this procedure for nonacute indications. Assessing PCI appropriateness using registry data is a challenging endeavor, especially since it is not possible to capture all the elements that are involved in the decision to proceed to PCI. Appropriateness use criteria are based only partially on hard evidence and are derived using expert consensus, and some disagreement on what is appropriate and what is uncertain is to be expected. Further, these criteria assume stress testing to be infallible, and basing appropriateness of PCI on a test with less than perfect sensitivity and specificity would automatically introduce a level of disagreement that cannot be avoided. I doubt any operator or institution could have total absence of inappropriate PCI using these criteria, and the best use of these criteria would be to assess the practice patterns at institutions that deviate significantly from the mean (in either direction).

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Myocardial Infarction, United States, Percutaneous Coronary Intervention


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