Focus on Appropriate Use of PCI May Be Driving Underuse for Patients Who Might Benefit

October 28, 2015

The 26th annual 2015 Scripps Cardiovascular Interventions Conference began the preconference seminar on Tuesday, October 27 with a talk entitled “A Compelling Case for Complex PCI in the Modern Era” by Dr. James McCabe, Medical Director of the University of Washington Cardiac Catheterization Laboratory, University of Washington Medical Center, Seattle, Washington.

Dr. McCabe began his presentation with a discussion of the under- and over-use of coronary revascularization. According to Hemingway et al (2001), the overuse of coronary revascularization has been controlled with scales such as the RAND-University of California at Los Angeles method, which help physicians determine an appropriateness score for coronary revascularization. However, the underuse of coronary revascularization was 34% (309 out of 908) for patients who qualified for percutaneous transluminal coronary angioplasty and 26% (352 out of 1353) of patients for whom coronary artery bypass surgery was appropriate (Hemingway et al. 2001). Hemingway’s study found that patients who received medical treatment over coronary revascularization were associated with worse clinical outcomes, which included more angina, nonfatal myocardial infarction and death.

As an example of the potential underuse of coronary revascularization procedures, Dr. McCabe presented the case of a 79-year-old with class 3 to 4 congestive heart failure (CHF) and stable ischemic heart disease. This patient had severe, diffuse, multivessel coronary artery disease with an occluded right coronary artery. This patient—who had severe lifestyle limitations—was transferred to 3 hospitals and told to consider hospice.

chip_populationAfter lengthy conversations with 25 family members, the patient decided on treatment with a protected percutaneous coronary intervention (PCI) procedure. The result was complete revascularization—Complete Revascularization in Higher-risk Patients is known as CHIP—and a reduction in CHF symptoms to class 2. This case highlights the benefits of the PCI procedure, which improved the quality of life of this patient.

Complete revascularization benefits patients and PCI is an acceptable alternative for patients with complex coronary artery disease, as observed in the SYNTAX trial (Ong et al. 2006; Mohr et al. 2013).

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