A study published on Oct. 10 in the Journal of the American College of Cardiology found that substantial underutilization and overutilization of coronary revascularization exists in clinical practice in Ontario, Canada.

Using the ACC's appropriate use criteria (AUC) for coronary revascularization, the study looked at 1,628 patients with stable coronary artery disease (CAD) between April 2006 and March 2007, and found that percutaneous coronary intervention (PCI) or coronary artery bypass grafting CABG was only performed in 69 percent of patients who had an appropriate indication for coronary revascularization. Coronary revascularization was associated with a lower adjusted hazard of death or acute coronary syndrome (ACS) (hazard ratio [HR]: 0.61; 95 percent confidence interval [CI]: 0.42 to 0.88) at three years compared with medical therapy in appropriate patients. Results also showed that among the patients who received coronary revascularization, 18 percent were considered uncertain and 14 percent were considered inappropriate.

The authors note that their data suggest higher revascularization rates in the U.S. compared to Canada may in part be related to higher rates of revascularization in patients with uncertain indications. "Future evaluation is needed to confirm whether discrepancies in appropriateness of coronary revascularization exist and whether they can be attributed to differences in implicit and explicit incentives associated with the different models of healthcare financing between the two countries," they add.