PCI: Nonclinical factors may influence physician decision-making

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August 16, 2007 By Grendel Burrell [1]


Cardiologists acknowledge data showing that PCI offers no reduction in the risk of death or myocardial infarction in patients with stable coronary artery disease, but in general believe that PCI benefits these patients. University of California authors, Grace A. Lin, MD, R. Adams Dudley, MD, MBA, and Rita F. Redberg, MD, MSc, report the results of a qualitative study utilizing 3 focus groups of California-based interventional and noninterventional cardiologists in the August 13 issue of the Archives of Internal Medicine. Focus group participants conferred on issues surrounding the evaluation and decision to perform PCI using hypothetical case scenarios (1).

The three focus groups included 20 cardiologists practicing in a variety of clinical settings in California. Participants were presented with 3 cases in which patients experienced no symptoms or atypical symptoms and stable single-vessel coronary artery disease (CAD). Physicians cited a belief in the benefits of treating ischemia and the open artery hypothesis, especially with drug-eluting stents as reasons for choosing treatment with PCI. The focus group members also stated the potential for regret if they did not intervene if to avert a possible cardiac event. Alleviation of patient anxiety and medicolegal considerations were also discussed. The authors state “Participants believed that, in patients undergoing coronary angiography, an ‘oculostenotic reflex’ prevailed and all significant amenable stenoses would receive intervention, even in asymptomatic patients.”

September 2007 marks the 30th anniversary of the first percutaneous coronary intervention (PCI) performed by Andreas Gruntzig. In the report of his first 5 cases, Gruntzig concluded that the technique, “if it proves successful in long-term follow-up studies, may widen the indications for coronary angiography and provide another treatment for patients with angina pectoris"(2) The first of the long-term follow up studies was completed 15 years later (3). Over the three decades following the initial case series, there has been tremendous growth in the application of PCI. Today clinicians have much data supporting the superiority of PCI when compared with medical therapy in patients with acute coronary syndromes, but the effectiveness of PCI in improving outcomes beyond a relief of angina in patients with stable coronary artery disease (CAD) remains unproven (4).

In the same issue of Archives, Dr. Mauro Moscucci, Division of Cardiology, University of Michigan, provides an editorial, titled “Behavioral Factors, Bias, and Practice Guidelines in the Decision to Use Percutaneous Coronary Interventions for Stable Coronary Artery Disease”. The author writes “While it is unquestionable that advancement in technology and adjunct pharmacological therapy have increased the safety and success rates of PCI, the procedure is still associated with a low but not insignificant risk of fatal and nonfatal complications, including vascular complications (approximately 3.0%), emergency coronary artery bypass grafting (approximately 0.5%), and in-hospital death (0.8%-1.6%).” (5)

Dr. Moscucci cites a retrospective analysis of data from the American College of Cardiology’s National Cardiovascular Data Registry in which Anderson et al (6) found that up to 8% of 412,617 procedures could be classified as a class III indication. The ACC/AHA/SCAI Joint Guidelines for PCI define class III as a “condition for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful.”(7) In the analysis by Anderson et al, procedures defined as inappropriate were associated with a 1.7% mortality rate, a 0.4% incidence of emergency coronary artery bypass grafting, and a 1.5% incidence of myocardial infarction (8).

Clearly, PCI is not without risks but noninvasive imaging may provide critical information. Dr. Moscucci concludes “The emergence of computed tomographic coronary angiography, which will likely widen the identification of asymptomatic CAD, and the emergence of other noncoronary vascular procedures, such as carotid stenting and renal artery stenting, should provide a stimulus for the rapid development and evaluation of appropriateness criteria that can be easily and safely applied in practice.”

In the study by Lin et al, some of the reasons provided by physicians for deciding to perform PCI are non clinical (1) studies focusing on the development of methods to help health care professionals more fully incorporate clinical evidence into their decision processes may be helpful as adjuncts to the task of choosing an invasive or non invasive approach to the management of stable CAD.

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  1. ref1 Grace A. Lin, MD; R. Adams Dudley, MD, MBA; Rita F. Redberg, MD, MSc . Cardiologists' Use of Percutaneous Coronary Interventions for Stable Coronary Artery Disease. Arch Intern Med. 2007;167:1604-1609

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