Metal or medication? Data may drive our decisions

Michael A Wilson

Michael A. Wilson, M.D., FACC, FCSAI
Cardiologist, assistant director of quality
Providence Heart and Vascular Institute

Published Oct. 6, 2014

When a patient is diagnosed with cardiovascular disease it’s tempting to opt for stents, a treatment with a long track record and proven benefits.

But just because a patient can receive coronary revascularization, should he? The landmark COURAGE trial caused many cardiologists to rethink PCI when the trial found that many patients with stable coronary artery disease fared as well with medical therapy as those who underwent a cardiac procedure.

This led the American College of Cardiology Foundation to publish appropriate-use criteria for coronary revascularization to help guide revascularization decision-making.1,2

Common clinical scenarios were rated based on current guidelines and expert review for appropriateness (A, appropriate; U, uncertain; I, inappropriate) using mainly the following variables:

  • Angina severity
  • Intensity of medical therapy
  • Stress test risk
  • Coronary anatomy

The table below shows how this data can be organized and used prospectively for low-risk stress tests and asymptomatic patients.

appropriateuse 

Source: Journal of the American College of Cardiology

A patient at greater risk for an adverse outcome (severe angina or higher expected mortality) should be treated more aggressively than a patient who has minimal symptoms, low-risk stress test results or a normal coronary anatomy.

Narrowing of the left main coronary artery, proximal LAD and multivessel diseases clearly are associated with greater risk and warrant more aggressive treatment. Patients with acute coronary syndromes almost always are appropriate for stenting, whereas an analysis of stable angina is more likely to reveal inappropriateness due to suboptimal medical therapy or an absence of provable ischemia.

Using data to determine treatment

In 2010, a cardiovascular work group from Providence analyzed original appropriate-use criteria and created an algorithm that allows teams to conduct quarterly assessments on appropriate-use data from 11 Providence cardiovascular centers across five states. This, combined with the National Cardiovascular Data Registry’s profiles, helps our specialists determine the best course of treatment.

By reviewing appropriate-use criteria before a procedure, we can get supporting documentation (stress test risk score, angina severity, current angina therapy, etc.) that will help determine if revascularization is necessary. Our data allow us to pinpoint the scenarios most likely to lead to inappropriate revascularization.

Still, there are limitations to using appropriate-use criteria for determining revascularization. The criteria do not take into account patient preference or intolerance to medication. The accuracy of nuclear stress testing diminishes in the presence of multivessel disease. Anatomic predictors may not correlate with the total ischemic burden, and angina equivalents may be misclassified. The criteria are not intended to be rigid, and there remains room for individualized care.

Yet prospective review of appropriate-use criteria has influenced clinical decision-making at Providence hospitals, leading to a significant drop in inappropriate revascularizations for stable angina patients and outcomes that consistently exceed national averages.

A poster illustrating the tool by Providence research analyst Stephanie Fine, MA, won first place at the National Cardiovascular Data Registry’s national meeting in 2013.

Early adoption and development of appropriate-use criteria, combined with a critical-case review process, has led to better decision-making, reduced patient risk and controlled costs of medical care.