What is the Association Between Coronary Angiography Patient Selection and PCI Appropriateness?

In a national sample of NCDR-participating hospitals, a newly published study has found that the performance of coronary angiography in asymptomatic patients is associated with lower rates of appropriate percutaneous coronary intervention (PCI), and higher rates of higher rates of inappropriate PCI. The study aimed to inform strategies that may minimize future inappropriate procedures, and to understand the association between patient selection for coronary angiography and PCI appropriateness.

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Published Aug. 25 in JAMA Internal Medicine  and led by Steven Bradley, MD, MPH, Veterans Affairs Eastern Colorado Health Care System, Denver, CO, the multi-center observational study examined 544 hospitals participating in the ACC's CathPCI Registry between July 1, 2009 and Sept. 30, 2013.

Results showed that of the 1,225,562 patients who underwent elective coronary angiography, 308,083 (21.5 percent) were asymptomatic. The hospital proportion of angiography among asymptomatic patients ranged from 1 percent to 73.6 percent, with a median of 24.7 percent and interquartile range of 15.9 percent-35.9 percent. Measuring by hospital quartile of asymptomatic patients at angiography, hospitals with higher rates of asymptomatic patients at angiography had higher median rates of inappropriate PCI (14.8 percent vs. 20.2 percent vs. 24.0 percent vs. 29.4 percent from lowest to highest quartile, P < .001 for trend), attributing to more frequent use of inappropriate PCI in asymptomatic patients at hospitals with higher rates of angiography in asymptomatic patients (5.4 percent vs. 9.9 percent vs. 14.7 percent vs. 21.6 percent from lowest to highest quartile, P < .001 for trend). The data also showed that hospitals with higher rates of asymptomatic patients at angiography had lower rates of appropriate PCI (38.7 percent vs. 33.0 percent vs. 32.3 percent vs. 32.9 percent from lowest to highest quartile, P < .001 for trend).

Based on their findings, the authors conclude that improving pre-procedural risk stratification and thresholds for coronary angiography may be one strategy to improve the appropriateness of PCI. "Our findings suggest patient selection for diagnostic angiography is associated with the quality of patient selection for PCI as determined by Appropriate Use Criteria," noted Bradley. "Although a strategy of clinical assessment immediately prior to PCI may minimize inappropriate use of the procedure, our findings suggest an opportunity to address patient selection upstream of the catheterization laboratory to optimize use of both angiography and PCI."

Keywords: Registries, Coronary Angiography, Catheterization, Coronary Artery Bypass, Angioplasty, Balloon, Coronary, National Cardiovascular Data Registries, CathPCI Registry

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