Pre-Angiography Symptom Assessment, Shared Decision Making Key to Improving PCI Appropriateness

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One in 4 patients undergoing elective coronary angiography in the United States is asymptomatic, according to a study published online August 25, 2014, ahead of print in JAMA: Internal Medicine. Moreover, the proportion of such patients widely varies among hospitals and is directly linked to the chances of appropriate percutaneous coronary intervention (PCI). 

“Strategies to improve patient selection for coronary angiography before proceeding to the cardiac catheterization laboratory may concurrently reduce inappropriate use of PCI and barriers to appropriate use of ad hoc PCI,” the authors say. 

Angiography performed in asymptomatic patients was positively associated with increased rates of inappropriate PCI (as defined by the 2012 appropriate use criteria) on a per-hospital basis (P < .001). A similar pattern was seen when hospitals were stratified into quartiles by median proportion of asymptomatic patients, which ranged from 12.1% in the lowest to 43.2% in the highest quartile (table 1). 

Table 1. Hospitals’ Median Percentage of ‘Appropriate’ Elective PCI Cases^a

^a P < .001 for all.  

At the patient level, most cases of inappropriate PCI occurred in asymptomatic patients being treated at hospitals in the higher quartiles. 

Stopping the ‘Diagnostic-Therapeutic Cascade’  

“These findings suggest that patient selection for coronary angiography is associated with the quality of patient selection for PCI as determined by the appropriate use criteria,” according to Dr. Bradley and colleagues. 

While “clinical assessment immediately before PCI may minimize inappropriate use of the procedure, our findings suggest an opportunity to address patient selection before proceeding to the catheterization laboratory to optimize the use of angiography and PCI,” they continue. 

They cite a long-acknowledged “diagnostic-therapeutic cascade” in which PCI is performed for obstructive lesions found during angiography whether or not revascularization is warranted. Assessing symptoms—or their absence—as part of patient selection might “reduce the occurrence of this cascade altogether,” the authors write. “Therefore, the onus of proper patient selection for PCI rests not only with the interventional cardiologist but also with the referring physicians (eg, cardiologists, internists, and family physicians) for coronary angiography.”

In an accompanying editorial, Grace A. Lin, MD, MAS, and R. Adams Dudley, MD, MBA, both of the University of California, San Francisco (San Francisco, CA), agree with the authors, citing the need to fight the ‘oculostenotic reflex’. 

“The medical culture appears to reinforce this cognitive bias toward intervention, resulting in non-evidence-based treatment decisions,” they write.

Informed Patients a Key in Decision Making  

To increase treatment appropriateness, guidelines must do more than merely encourage physicians to engage in shared decision-making with patients, according to the editorial. “Spreading best practices in this way can be a slow process, particularly if incentives are not aligned and there is little transparency in care,” Drs. Lin and Dudley say.

They also recommend creation of a tool for measuring decision quality. This would enable physicians “to determine whether the treatment for stable angina reflects the evidence base and the preferences of well-informed patients,” they write. Additionally, the editorial suggests “informed patients will be more likely to … decline procedures in situations where there are no clear benefits.” 

Lastly, Drs. Lin and Dudley call for revised appropriate use criteria that include decision quality as a requirement. As it stands now, a given procedure could be ‘appropriate’ but still emerge from a poor-quality decision “if the patient was not well informed or their preferences were not taken into account. 

“Physicians are integral to the decision-making process, and thus they hold the key to changing it,” they conclude. “Physicians should be held accountable for ensuring that treatment decisions are evidence-based and patient-centered.”

1. Bradley SM, Spertus JA, Kennedy KF, et al. Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry. JAMA Intern Med. 2014;Epub ahead of print.

2. Lin GA, Dudley RA. Fighting the “oculostenotic reflex [invited commentary].” JAMA Intern Med. 2014:Epub ahead of print.

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