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Impact of National Clinical Guideline Recommendations for Revascularization of Persistently Occluded Infarct-Related Arteries
Study Questions:
What has been the impact of Occluded Artery Trial (OAT) results and consequent change in guideline recommendations for percutaneous coronary intervention (PCI) for treatment of persistently occluded infarct-related arteries (IRA)?
Methods:
The investigators identified all patients enrolled in the CathPCI Registry®, from 2005 to 2008, undergoing catheterization more than 24 hours after myocardial infarction (MI) with a totally occluded native coronary artery and no major OAT exclusion criteria. They examined trends in monthly rates of PCI for occlusions after OAT publication and after guideline revisions. Because reporting of diagnostic catheterizations was not mandatory, the authors examined trends among hospitals in the highest quartile for reporting of diagnostic procedures. The crude proportion of PCI for occlusions identified after MI was compared using the χ2 rank–based group means score test.
Results:
A total of 28,780 patient visits from 896 hospitals were included. Overall, the investigators found no significant decline in the adjusted monthly rate of PCI of occlusions after publication of OAT (odds ratio [OR], 0.997; 95% confidence interval [CI], 0.989-1.006) or after guideline revisions (OR, 1.007; 95% CI, 0.992-1.022). Among hospitals consistently reporting diagnostic catheterizations, there was no significant decline after OAT publication (OR, 1.018; 95% CI, 0.995-1.042), and there was a trend toward decline after guideline revisions (OR, 0.963; 95% CI, 0.920-1.000).
Conclusions:
The authors concluded that the results of the OAT and consequent guideline revisions have not been fully incorporated into clinical practice in a large cross-section of hospitals in the United States.
Perspective:
This study found no change in the adjusted rate of PCI for total occlusions identified at least 24 hours after MI following the publication of the OAT or the revision of the major guidelines. It appears that PCI of total occlusions identified greater than 24 hours after MI remains commonplace despite little evidence to support its use in stable patients and new clinical practice guidelines recommending against it. The factors accounting for this lack of incorporation of evidence-based therapy in clinical practice despite national guideline recommendations need further study.
Keywords: Registries, Myocardial Infarction, Sodium Chloride, Avena, Musa, Catheterization, Coronary Vessels, United States, Percutaneous Coronary Intervention
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