SCAI Updates Recommendations for Ad Hoc PCI

Ad hoc percutaneous coronary intervention (PCI) has often been viewed as beneficial to patients who need it, negating the need for a second procedure and saving costs. However, a newly revised set of clinical recommendations suggests that physicians should give careful thought and discussion to unplanned procedures before simply moving forward.

In a consensus statement, endorsed by the Society for Cardiovascular Angiography and Interventions (SCAI), and published online November 29, 2012, ahead of print in Catheterization and Cardiovascular Interventions, James C. Blankenship, MD, of Geisinger Medical Center (Danville, PA), and colleagues outline the best circumstances for ad hoc PCI and update the recommendations to allow for patient preference with proper education.

According to the document, ad hoc PCI should only be performed as part of a comprehensive program that includes:

• A patient consent process that involves the patient in shared decision making prior to sedation and fully informs them of the risks and benefits of ad hoc PCI and alternative treatments
• Data collection to determine appropriateness, including severity of angina, ischemia, and the patient’s past experience with medications
• Patient risk assessment, including short- and long-term risks of both PCI and alternative treatments, such as optimal medical therapy and cardiac surgery
• Administration of proper drugs and fluids to pretreat patients who may be candidates for ad hoc PCI
• Appropriate scheduling to allow time for ad hoc PCI

In addition, the recommendations focus on performing ad hoc PCI in specific cardiac conditions. First, they advise that the procedure is the best treatment for patients with MI. For stable heart disease, ad hoc PCI should be considered and has the greatest benefit when a trial of optimal medical therapy has failed. However, if medications have not yet been tried, the benefits of the procedure should be compared with medical treatment. Lastly, ad hoc PCI for complex multivessel or unprotected left main disease should be reserved for unusual circumstances in which surgical consultation has already occurred or is clearly not an appropriate consideration due to comorbidities or other factors and in which patients have been fully educated about risks and benefits of the procedure.

Ad Hoc Procedure OK with Careful Thought, Discussion

In a telephone interview with TCTMD, Dr. Blankenship said, “There have been several studies published since 2004 [when these guidelines were last updated], and they show that the incidence of ad hoc PCI has been increasing . . . and that it does seem to be a safe strategy,” he said. “We’re maintaining that it continues to be a very safe strategy, at least as safe as staged PCI.”

In addition, Dr. Blankenship commented, “We are reinforcing some of the other ideas that have been espoused recently in that even as the frequency of [ad hoc PCI] is increasing, there are certainly circumstances where it is important to stop after the diagnostic portion and further consider what you are going to do.”

One potential problem, he continued, lies with reimbursements to both hospitals and physicians, since separate, staged PCIs receive higher reimbursements than a single ad hoc procedure. “One of our concerns is that the Centers for Medicare and Medicaid Services (CMS) would try to bundle everything, and even private insurers might take the position that if you’re not doing it at the same time that there’s something wrong with you,” Dr. Blankenship explained. “So we want to make the point loud and clear to CMS, the government, and to insurers, that there are many circumstances where putting off the procedure is a perfectly appropriate thing to do and that they should not penalize physicians for doing what is the right thing in cases where people do put off the procedure to another time.”

An additional consideration is that patients increasingly want to have a role in the decision making process and want to be fully informed, he said. A preprocedural conversation with a patient who might potentially be a candidate for ad hoc PCI, while lengthy and full of information, is worthwhile if the physician deems it necessary. However, only “getting informed consent for a simple PCI and then finding that they have complex disease and then launching into a very complex, relatively high-risk intervention without having gone through that process with the patient beforehand” is wrong, Dr. Blankenship stressed, adding that this most likely happens too often in clinical practice.

Elevating Patient Preference

Gregg W. Stone, MD, of Columbia University Medical Center (New York, NY), told TCTMD in a telephone interview that ad hoc PCI has come into question over the last few years “because it can preclude informed patient decision making and it can also make impossible the heart team approach.”

On the other hand, he noted, “there’s a clear likability factor of ad hoc PCI. It’s less expensive, patients like it because they are only having one procedure rather than two, and there are clearly some complications that are decreased because you are only doing one procedure rather than two.”

As clinicians in Europe have recently taken the approach that ad hoc PCI should not be used in the vast majority of cases, Dr. Stone said “it was very timely for the US guidelines to come out. I think the US guidelines take a more appropriate and realistic view, balancing the potential benefits, but also the disadvantages of ad hoc PCI, and I think they get it just about right.”

Still, he said he “would emphasize a little more strongly that ad hoc PCI in patients with stable coronary disease has to take into account patient preference, even more so than has been emphasized. This document notes that ad hoc PCI might not be consistent with the appropriate use criteria, which require failure of 2 antianginal medications, but there’s no evidence-based medicine that suggests that that’s an appropriate way to treat patients.”

 

---

Source:
Blankenship JC, Gigliotti OS, Feldman DN, et al. Ad hoc percutaneous coronary intervention: A consensus statement from the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2012;Epub ahead of print.

 

 

Related Stories:

• North Carolina Study Sparks Debate Over National PCI Trends
• Substantial Decline Seen in CABG Over Last Decade, But PCI Rates Unchanged
• Pressing 'Pause:' A Call to Reexamine Ad Hoc PCI