Most PCIs (such as balloon angioplasty) performed in US for acute indications appear warranted

July 5, 2011, JAMA and Archives Journals

In an examination of the appropriateness of the widespread use of percutaneous coronary interventions (PCIs), researchers found that of more than 500,000 PCIs included in the study, nearly all for acute indications were classified as appropriate, whereas only about half of PCIs performed for nonacute indications could be classified as appropriate, according to a study in the July 6 issue of JAMA.

"Approximated 600,000 percutaneous coronary interventions [procedures such as or stent placement used to open narrowed coronary arteries] are performed in the United States each year, at a cost that exceeds $12 billion. Patients who undergo PCI are exposed to risks of periprocedural complications and longer-term bleeding and stent . Moreover, recent trials in without have shown that PCI, compared with , may provide only a modest population-average improvement in . Given the cost and invasiveness of PCI, determining the extent to which PCI procedures are performed for appropriate and inappropriate indications could identify procedural overuse and areas for quality improvement and cost savings," according to background information in the article. Recently, appropriate use criteria for were jointly developed by 6 professional organizations to support the rational and judicious use of PCI.

Paul S. Chan, M.D., M.Sc., of Saint Luke's Mid America Heart and Vascular Institute, Kansas City, Mo., and colleagues conducted a study to quantify the proportion of PCIs classified as appropriate, of uncertain , and as inappropriate for acute as well as nonacute indications. The study included data from patients within the National Cardiovascular Data Registry undergoing PCI between July 2009 and September 2010 at 1,091 U.S. hospitals. The appropriateness of PCI was determined using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute indication (ST-segment elevation myocardial infarction – a certain pattern on an electrocardiogram following a heart attack; non-ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication.

Of 500,154 procedures classified, 103,245 (20.6 percent) were for ST-segment elevation myocardial infarction, 105,708 (21.1 percent) for non-ST-segment elevation myocardial infarction, 146,464 (29.3 percent) for high-risk unstable angina, and 144,737 (28.9 percent) for nonacute elective indications. Based on the appropriate use criteria definition for acute procedures, 355,417 PCIs (71.1 percent) were for acute indications and 144,737 (28.9 percent) were for nonacute indications. Heart attack comprised 58.8 percent of all acute procedures, while high-risk unstable angina comprised 41.2 percent.

The researchers found that the vast majority (98.6 percent) of acute PCIs were classified as appropriate, with 0.3 percent classified as uncertain and 1.1 percent as inappropriate. Overall, 50.4 percent of nonacute PCIs were classified as appropriate, while 38.0 percent were for uncertain indications and 11.6 percent were for inappropriate indications. In general, compared with procedures classified as appropriate and uncertain, inappropriate PCIs were more likely to occur in patients with no angina, low-risk non-invasive stress testing results or suboptimal antianginal therapy.

There was substantial hospital-level variation in the proportion of inappropriate procedures for nonacute indications. Hospitals in the lowest quartile had rates of inappropriate PCI of 6 percent or lower, while the rate of inappropriate PCI was greater than 16 percent among hospitals in the highest quartile. Analysis of the data suggested an 80 percent greater likelihood of patients with identical clinical characteristics receiving an inappropriate PCI at one randomly selected hospital as compared with another.

"Collectively, these findings suggest an important opportunity to examine and improve the selection of patients undergoing PCI in the non-acute setting," the authors write.

"Better understanding of the clinical settings in which inappropriate PCIs occur and reduction in their variation across hospitals should be targets for quality improvement."

Explore further: Most heart-attack patients needing procedure at another hospital not transferred in recommended time

More information: JAMA. 2011;306[1]53-61.

Related Stories

Most heart-attack patients needing procedure at another hospital not transferred in recommended time

June 21, 2011
Only about 10 percent of patients with a certain type of heart attack who need to be transferred to another hospital for a PCI (procedures such as balloon angioplasty or stent placement used to open narrowed coronary arteries) ...

Recommended for you

Starting periods before age of 12 linked to heightened risk of heart disease and stroke

January 15, 2018
Starting periods early—before the age of 12—is linked to a heightened risk of heart disease and stroke in later life, suggests an analysis of data from the UK Biobank study, published online in the journal Heart.

'Decorated' stem cells could offer targeted heart repair

January 10, 2018
Although cardiac stem cell therapy is a promising treatment for heart attack patients, directing the cells to the site of an injury - and getting them to stay there - remains challenging. In a new pilot study using an animal ...

Exercise is good for the heart, high blood pressure is bad—researchers find out why

January 10, 2018
When the heart is put under stress during exercise, it is considered healthy. Yet stress due to high blood pressure is bad for the heart. Why? And is this always the case? Researchers of the German Centre for Cardiovascular ...

Two simple tests could help to pinpoint cause of stroke

January 10, 2018
Detecting the cause of the deadliest form of stroke could be improved by a simple blood test added alongside a routine brain scan, research suggests.

Heart-muscle patches made with human cells improve heart attack recovery

January 10, 2018
Large, human cardiac-muscle patches created in the lab have been tested, for the first time, on large animals in a heart attack model. This clinically relevant approach showed that the patches significantly improved recovery ...

Place of residence linked to heart failure risk

January 9, 2018
Location. Location. Location.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.