Rates of "rarely appropriate" PCI may increase if appropriate use criteria (AUC) were modified to incorporate findings from recent randomized clinical trials, according to a research letter published Sept. 21 in JAMA Internal Medicine.

Ali O. Malik, MD, MSc, et al., used data from ACC's CathPCI Registry to determine the potential implications of the ISCHEMIA trial on the appropriateness of PCI among patients with stable ischemic heart disease (SIHD). The researchers looked at patients in the registry between April 2018 and June 2019. Patients who underwent PCI for acute coronary syndromes, staged revascularization procedures, or who presented with cardiac arrest or shock were excluded from the study. PCIs were classified as appropriate, maybe appropriate or rarely appropriate based on current AUC definitions and on modified AUC definitions based on the ISCHEMIA trial. The modified AUC recategorized all PCIs performed for asymptomatic patients without left main coronary artery disease and/or left ventricular dysfunction (defined as an ejection fraction <35%) as rarely appropriate.

The final cohort comprised 352,376 patients with SIHD with a mean age of 68 years, including 40,171 patients (11.4%) who were nonwhite and 106,065 women (30.1%). Among all patients, 152,907 (43.4%) had diabetes, 201,417 (57.2%) were current or recent smokers, and 58,295 (16.5%) had chronic lung disease. At the time of PCI, 61,651 patients (17.5%) were asymptomatic or had nonanginal chest pain.

Based on current AUC, 120,058 PCIs (56.2%) were classified as appropriate, 86,547 (40.5%) as maybe appropriate, and 7,148 (3.3%) as rarely appropriate. With the modified AUC ratings, 120,044 PCIs (50.8%) were classified as appropriate, while 63,648 (26.9%) were maybe appropriate and 52,590 (22.3%) were rarely appropriate. The increase in the number of rarely appropriate PCIs under the modified AUC was due to a reclassification of 45,442 asymptomatic patients whose PCIs were initially classified as appropriate (14, 0.03%), maybe appropriate (22,899, 50.4%), or unable to be classified (22,529, 49.6%).

According to the researchers, if AUC were modified to incorporate randomized clinical trials, rates of rarely appropriate PCIs "may be nearly sevenfold higher compared with current AUC ratings." Given the costs and risks of PCI in patients with SIHD, the findings "underscore the importance of updating clinical guidelines and AUC to be consistent with the robust evidence base," they conclude.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Acute Coronary Syndrome, Percutaneous Coronary Intervention, Stroke Volume, Myocardial Ischemia, Chest Pain, Registries, Heart Arrest, Ventricular Dysfunction, Left, Diabetes Mellitus, Lung Diseases, National Cardiovascular Data Registries, CathPCI Registry

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