Appropriateness of Coronary Revascularization for Patients Without Acute Coronary Syndromes

Hannan, Edward L.; Cozzens, Kimberly; Samadashvili, Zaza; Walford, Gary; Jacobs, Alice K.; Holmes, David R.; Stamato, Nicholas J.; Sharma, Sanjeev; Venditti, Ferdinand J.; Fergus, Icilma; King, Spencer B.

doi:10.1016/j.jacc.2012.01.050

Cited by 83 publications

(53 citation statements)

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“…Application of the AUC has demonstrated quality gaps in patient selection for PCI, with as many as 1 in 6 elective (nonacute) PCIs being classified as inappropriate. [3][4][5] Whether the use of inappropriate PCI has changed in response to a growing emphasis on proper patient selection and procedural appropriateness is unknown.…”

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confidence: 99%

Temporal Trends in Percutaneous Coronary Intervention Appropriateness

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Temporal Trends in Percutaneous Coronary Intervention Appropriateness

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“…Recently, the ACC Foundation/Society for Cardiovascular Angiography and Interventions/Society for Thoracic Surgeons/American Association for Thoracic Surgery/AHA/American Society of Nuclear Radiology released appropriateness criteria for coronary revascularization to serve as a supplement to the ACC/ AHA guideline documents [87] . Hannan et al [88] studied the appropriateness of PCI and CABG performed in New York for patients without acute coronary syndrome or previous CABG. Of the 8168 patients undergoing CABG, 90.0% were appropriate for revascularization, 1.1% were inappropriate, and 8.6% were uncertain.…”

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confidence: 99%

Myocardial ischemia is a key factor in the management of stable coronary artery disease

Iwasaki¹

2014

WJC

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Previous studies demonstrated that coronary revascularization, especially percutaneous coronary intervention (PCI), does not significantly decrease the incidence of cardiac death or myocardial infarction in patients with stable coronary artery disease. Many studies using myocardial perfusion imaging (MPI) showed that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit, whereas for patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality. There is some evidence that revascularization in patients with no or mild ischemia is likely to result in worsened ischemia, which is associated with increased mortality. Studies using fractional flow reserve (FFR) demonstrate that ischemia-guided PCI is superior to angiography-guided PCI, and the presence of ischemia is the key to decisionmaking for PCI. Complementary use of noninvasive MPI and invasive FFR would be important to compensate for each method's limitations. Recent studies of appropriateness criteria showed that, although PCI in the acute setting and coronary bypass surgery are properly performed in most patients, PCI in the non-acute setting is often inappropriate, and stress testing to identify myocardial ischemia is performed in less than half of patients. Also, some studies suggested that revascularization in an inappropriate setting is not associated with improved prognosis. Taken together, the presence and the extent of myocardial ischemia is a key factor in the management of patients with stable coronary artery disease, and coronary revascularization in the absence of myocardial ischemia is associated with worsened prognosis.© 2014 Baishideng Publishing Group Co., Limited. All rights reserved.Key words: Coronary artery bypass surgery; Coronary revascularization; Fractional flow reserve; Myocardial ischemia; Myocardial perfusion imaging; Percutaneous coronary intervention Core tip: Studies of myocardial perfusion imaging demonstrate that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit. For patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality probably because of worsened ischemia. Studies using fractional flow reserve demonstrate that ischemia-guided percutaneous coronary intervention (PCI) is superior to angiography-guided PCI, and the presence of ischemia is the key factor in decision-making for PCI. Thus, myocardial ischemia is a key factor in the management of patients with stable coronary artery disease.Iwasaki K. Myocardial ischemia is a key factor in the management of stable coronary artery disease. World J Cardiol

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“…The study shows that 91% of patients undergoing PCI had lesions in one or two vessels, without involvement of the proximal left anterior descending artery or were under clinical treatment which was considered insufficient [4].…”

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A medicina baseada em evidências e a coronariopatia

Rocha¹

2012

Revista Brasileira De Cirurgia Cardiovascular

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In November, we had two important works presented that will change the course of the treatment of coronary artery disease. The presentation of the fifth follow-up year of SYNTAX study [1] and the results of the FREEDOM [2] demonstrated a clear advantage on the results of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) with drug-eluting stents in triple vascular diabetic patients with trunk injuries of left main coronary artery.In its fifth year, the SYNTAX shows that mortality from cardiac causes was 9% for PCI and 5.3% for CABG, myocardial infarction (MI) in 5 years: 3.8% for CABG and 9.7% for PCI. The need for another revascularization was 25.9% for PCI and 13.7% for CABG.The FREEDOM, study sponsored by the stent manufacturing industry, also demonstrates a clear advantage of the results of CABG compared to PCI. The all-cause mortality in 5 years was 18.7% in the CABG and 26.6% in PCI (P = 0.005), AMI 6% for CABG and 13.9% for PCI (P <0.001). However, patients undergoing CABG had more cerebrovascular accidents (5.2% versus 2.4%).The evidence-based medicine will change the reality, with several medical and financial implications. Health plans and SUS (Unified Health System) will limit the indications of inappropriate practices, for their own survival. We, as doctors, have to specify the procedures well, avoiding unnecessary costs for payers, in order to achieve adequate remuneration.The PCI solution seemed modern and suitable for coronary insufficiency. In 2007, the COURAGE study began to change that impression, demonstrating that clinical treatment is better than PCI for treatment of stable angina [3]. However, despite always hearing that the prosthesis would develop continually, after seeing the results of the FREEDOM and SYNTAX made us disbelievers. Some multinationals are discouraging their production or closing line of stents and devices due to the fear of legal issues and also a fall in the profitability of this market.In the United States, some doctors are being prosecuted and jailed for indication of inadequate therapeutic procedures. Moreover, ethical issues should be raised. No procedure is risk-free, if the indication is not precise, certain patients will certainly perish or suffer serious complications, which is unacceptable.We have observed speeches totally unfounded used in our day-to-day activities who have influenced on the indication of procedures, such as the culprit lesion. It is not easy to understand what a culprit lesion is; we know that there are patients with severe injuries in one, two or three major coronary arteries. The clinical presentation, characteristics and anatomy, besides the severity of coronary lesions, are the factors that determine the indication for revascularization procedures.A very interesting article was published this year, about the real world in the United States for the treatment of coronary artery disease. The study shows that 91% of patients undergoing PCI had lesions in one or two vessels, without involvement of the proximal ...

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Appropriateness of Coronary Revascularization for Patients Without Acute Coronary Syndromes

Cited by 83 publications

References 18 publications

Temporal Trends in Percutaneous Coronary Intervention Appropriateness

Temporal Trends in Percutaneous Coronary Intervention Appropriateness

Myocardial ischemia is a key factor in the management of stable coronary artery disease

A medicina baseada em evidências e a coronariopatia

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