This is a fun barometer of what may be on interventionalists' technical and operational radars (albeit the numbers are small). And to try to measure change over time, we compared this year's results with those from last year's poll; some of the choices were the ranked the same. So here are the interventionalist's resolutions for 2021 (Figure 1) with a comparison to 2020 (Figure 2).

Figure 1

Figure 2

The number 1 choice this year was new and an outgrowth of ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches)¹ results reflecting a move toward greater use of computed tomography angiography (CTA) in place of stress nuclear imaging to evaluate chest pain. This reflects a move toward anatomic screening based on evidence that CTA results have predictive value² as well as identifying critical left main disease without traditional coronary angiography.

The number 2 choice is a repeat from 2020 and reflects an important emphasis on only revascularizing hemodynamically significant lesions using fractional flow reserve, which remains a priority (it was first place in 2020).

The number 3 choice is another new item, again reflecting results of ISCHEMIA¹ in which medical management was considered appropriate treatment for an isolated, significant, proximal left anterior descending lesion.

It was a 3-way tie for the number 4 choice that includes the use of intravascular imaging to assess adequacy of stent placement. In 2020, the same item was a tie for second place.³ Also included is ultrasound assessment for large bore vascular access, which is a positive increase in ranking from 2020 when it ranked ninth despite data to support the impact on clinical outcomes.

This year's top 5 results are encouraging, showing a focus on developing, admittedly potentially disruptive, changes such as utilizing CTA for ischemia evaluation as well as accepting medical therapy as appropriate for single vessel coronary disease. Repeats from last year note interest in the importance of hemodynamically documented ischemia as a prerequisite for stenting as well as using intravascular imaging, not angiography, to achieve optimal late interventional outcomes. Lower-ranked choices could represent opportunities that are important but may already be a regular part of practice for some interventionalists. For instance, cardiovascular risk-modifying therapies post-intervention was part of the 3-way tie for number 4 in 2021 but ranked second in 2020. Although many may consider this "done" and thus no longer a priority, appropriate lipid management post-percutaneous coronary intervention is still an opportunity after acute coronary syndromes.

The number 5 choice was complete revascularization in multivessel interventions, which ranked similarly in 2020. Again, many may feel they have already updated their percutaneous coronary intervention strategy to include this, but data do not support this in many cases.

The number 6 choice was the now-accepted strategy to consider primary angioplasty as optimal acute ST-segment elevation myocardial infarction care in the face of coronavirus disease 2019 infection given staff have adequate personal protective equipment.⁴

Lastly, the number 7 choice is a new opportunity for guideline compliance. Heart failure guidelines suggest the importance of identifying underlying ischemia in new onset heart failure, but recent data show this is infrequently accomplished.⁵

This poll provides a cautious barometer of what's on interventionalists' radars for practice updates and perhaps suggests there are still areas where practice variation may reveal opportunities for improvement.

Thanks to all who participated.

References

1. Maron DJ, Hochman JS, Reynolds HR, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med 2020;382:1395-407.
2. SCOT-HEART Investigators, Newby DE, Adamson PD, et al. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med 2018;379:924-33.
3. Choi KH, Song YB, Lee JM, et at. Impact of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention on Long-Term Clinical Outcomes in Patients Undergoing Complex Procedures. JACC Cardiovasc Interv 2019;12:607-20.
4. NACMI: Unique Registry Collaboration Aims to Improve Outcomes, Management of STEMI Patients With COVID-19 (ACC.org). Oct. 14, 2020. Available at https://www.acc.org/latest-in-cardiology/articles/2020/10/12/13/17/weds-1230pm-nacmi-north-american-covid-19-stemi-registry-tct-2020. Accessed February 5, 2021.
5. O'Connor KD, Brophy T, Fonarow GC, et al. Testing for Coronary Artery Disease in Older Patients With New-Onset Heart Failure: Findings From Get With The Guidelines-Heart Failure. Circ Heart Fail 2020;13:e006963.

Clinical Topics: Acute Coronary Syndromes, COVID-19 Hub, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Lipid Metabolism, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Echocardiography/Ultrasound, Nuclear Imaging, Chronic Angina

Keywords: Coronary Angiography, Fractional Flow Reserve, Myocardial, Coronary Artery Disease, Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Personal Protective Equipment, COVID-19, Cardiovascular Diseases, Risk Factors, Percutaneous Coronary Intervention, Ultrasonography, Chest Pain, Stents, Angioplasty, Heart Failure, Lipids

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