Journal Wrap
Kim Eagle, MD, and the editors of, present relevant articles taken from various journals

Geographic Variation in Appropriate PCI

In geographical regions with lower percutaneous coronary intervention (PCI) rates, a greater proportion of PCI are considered appropriate, according to a recent study published in PLOS ONE. The study also found that in areas where a greater number of PCIs are performed, a greater number of procedures are elective.

In this study, Michael P. Thomas, MD, FACC, and colleagues examined 380,981 patients from 178 hospital referral regions, or regional health care markets for tertiary care than contain at least one hospital performing major cardiovascular procedures and neurosurgery. The patients all underwent PCI in 2010 at hospitals participating in the ACC’s CathPCI Registry. To determine appropriateness, the authors used the 2012 ACC/American Heart Association/The Society for Cardiovascular Angiography and Interventions Appropriate Use Criteria (AUC). Geographical variation was determined by dividing the country into hospital referral regions. The rate of PCI at each hospital referral region was calculated and the regions were divided into quintiles with Quintile 5 representing the highest utilization rate. Data from the CathPCI registry was used to evaluate patient characteristics, procedural appropriateness and in-hospital outcomes across the quintiles. PCIs were categorized as appropriate, inappropriate, uncertain or unmappable, which is defined as cases where no stress test was performed and the presentation was non-acute coronary syndrome (ACS) or for a non-ACS presentation with a positive stress test and an unavailable result.

The researchers found that in areas of lower PCI utilization, there were higher rates of appropriate PCI with 76.5% of PCIs in Quintile 1 considered appropriate and 72.7% of PCIs in Quintile 5 considered appropriate. There was an increase in rates of unmappable PCIs in higher utilizations—11.3% in Quintile 1 and 14.3% in Quintile 5—and there was a smaller variation in the rates of inappropriate PCI, from 3.92% in the lowest volume quintile compared to 4.19% in the higher quintiles.

The rates of appropriate PCIs for acute indication was high (95.14%-96.05%) across all quintiles, however, the rates of appropriate PCIs for non-acute indications for each quintile varied across regions, decreasing from Quintile 1 to Quintile 5. The rates of unmappable PCIs increased substantially from Quintile 1 to Quintile 5, with smaller variation in the rates of inappropriate PCI. There was no difference in risk-adjusted mortality across the quintiles.

Regarding the unmappable cases, the authors write that “although a large proportion of unmapple cases make it difficult to precisely determine appropriateness, it is possible that some of the unmappable cases are discretionary and PCI may be able to be avoided.” They add that the “large variation in unmappable PCIs may provide a valuable target for quality improvement. Since there is little clinical downside to delaying PCI in the setting of stable CAD, ensuring appropriate risk stratification to better clarify the potential benefits of PCI seems reasonable.”

The authors conclude that these findings “support the need to explore utility of routine application of AUC classification prior to elective PCI as a strategy to optimize utilization of PCI.”

Thomas MP, Parzynski CS, Curtis JP, et al. PLOS ONE. 2015;doi:10.1371/journal.pone.0138251.

Hypertensive Patients May Face Risk From Beta-Blockers During Surgery

In patients with uncomplicated hypertension undergoing noncardiac surgery, antihypertensive treatment with beta-blockers may lead to an increased risk of major adverse cardiovascular events (MACEs) and all-cause mortality. These findings were recently published in JAMA Internal Medicine.

The use of beta-blockers during surgery is currently being reevaluated due to concerns regarding previous studies. The researchers of this study, led by Mads E. Jørgensen, MB, hoped to determine the risk of perioperative beta-blocker use in patients free of cardiac, renal and liver disease.

The researchers identified all noncardiac surgeries performed in Denmark between 2005 and 2011 in patients at least 20 years of age. They then identified hypertensive patients treated with at least two antihypertensive drugs (beta-blockers, renin-angiotensin [RAS] inhibitors, thiazides or calcium channel antagonists). The primary outcomes were MACEs and all-cause mortality within 30 days of surgery.

The final cohort contained a total of 55,320 hypertensive patients with 14,644 patients treated with beta-blockers and 40,676 patients treated with other antihypertensive drugs. Baseline characteristics between the groups were similar, although more women (64.9%) than men (57.1%) received beta-blockers. The use of beta-blockers declined between 2005 (35.0%) and 2011 (29.5%).

At 30 days, the incidence of MACE and mortality was 1.32% and 1.93% in patient with beta-blockers compared to 0.84% and 1.32% in patients treated with other antihypertensive drugs only. Cardiovascular death was higher in patients treated with beta-blockers (0.90% vs. 0.45%, p < .001), but not nonfatal stroke (0.23% vs. 0.21%; p = 0 .68) and nonfatal acute myocardial infarction (0.18% vs. 0.17%; p = 0.81).

All regimens with beta-blockers were associated with a statistically significant increased risk of MACE and all-cause mortality compared to RAS inhibitors and thiazides. The exception was patients treated with beta-blockers and two other antihypertensive drugs, who were not at an increased risk. Patients treated with any combination of other hypertensive drugs were also not at risk. The associated number needed to harm (NNH) for beta-blocker treatment was more pronounced in patients at least 70 years old (NNH, 140), men (NNH, 142), and those undergoing acute surgery (NNH, 97).

In an Journal Scan, Prashant Vaishnava, MD, notes that this study adds to the controversy about perioperative beta-blockade therapy. “While current guidelines recommend continuation of perioperative beta-blocker therapy in those who are taking such treatment chronically, this is based on limited literature and there is even greater uncertainty about the initiation of beta-blockade perioperatively in those not already taking this treatment,” he writes. “The current analysis adds to other recent studies that caution against the use of perioperative beta-blocker therapy in select patients and settings. Indeed, antihypertensive treatment with beta-blocker may be associated with increased adverse perioperative events. However, we need more studies before we can definitively say whether this relationship is causal or simply unmeasured selection bias.”

Jørgensen ME, Hlatky MA, Køber L, et al. JAMA Intern Med. 2015;Oct 5:[Epub ahead of print]

PCI Outcomes Not Dependent on Interventional Cardiology Certification

Interventional Cardiology (ICARD) certification is not a strong predictor of patient outcomes in percutaneous coronary intervention (PCI) procedures, according to results from a recent study published in Circulation.

Using data from the ACC’s CathPCI Registry, researchers examined the association of American Board of Internal Medicine (ABIM) physician certification in ICARD with patterns of care and outcomes of patients receiving PCI between Jan. 1, 2010, and Dec. 31, 2010. A total of 5,175 physicians who had performed a total of 510,708 PCI procedures during the study period were included. ICARD certified cardiologists performed 78.2% of the procedures, and on average they performed more PCIs in 2010 than non-certified physicians (111.8 PCIs vs. 75.8 PCIs) and a higher proportion performed at least 50 PCIs. Additionally, a higher percentage of ICARD certified physicians practiced in an academic setting.

Patients treated by ICARD certified physicians were less likely to be discharged on aspirin, thienopyridines and statins after PCI. Higher proportions of PCIs performed by ICARD certified physicians were considered inappropriate (13.1% vs. 11.8%, p = 0.002) and appropriate (24.7% vs. 23.1%, p = 0.038). Those classified as uncertain were similar.

The outcomes of patients treated by certified and non-certified physicians was similar, but there was a higher risk of mortality and emergency coronary artery bypass grafting (CABG) in patients treated by non-ICARD certified physicians. However, the authors write that the overall event rates were low and the clinical significance of the differences may be modest. There were no significant differences in the adjusted risks of bleeding, vascular complications, and the composite endpoint of any adverse outcomes.

According to the study authors, these findings could be explained by the fact that PCI is now much safer and more reliable than when it was first developed and that the non-certified group included both physicians who had never been certified and those who had allowed their certification to lapse. Additionally, “it is possible that the qualities and abilities currently captured by the certification process may not be the same as those needed to discriminate between physicians who perform PCI. “For example, the certification exam can assess an individual’s knowledge but cannot test for their ability to make decisions under pressure, manual dexterity, and the ability to recognize and treat complications.

According to the authors, “The requirements for obtaining certification in ICARD are rigorous. Given this rigor, it is notable that the majority of practicing interventional cardiologists have obtained ABIM ICARD certification.” ICARD certification was introduced in 1999, and only 2.9% of those who completed training after that were not certified.

“In conclusion, we found that the outcomes of patients undergoing PCI were excellent and varied modestly depending on the certification status of the performing physician,” the authors write. “Our findings suggest there is an opportunity to enhance the value of subspecialty certification.”

Fiorilli PN, Minges KE, Curtis JP, et al. Circulation. 2015; Sept 18:[Epub ahead of print]

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Prevention, Hypertension

Keywords: CardioSource WorldNews, Adrenergic beta-Antagonists, Antihypertensive Agents, Certification, Surgical Procedures, Elective, Hypertension, Percutaneous Coronary Intervention

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