Majority of Stable CAD Patients Misunderstand Purpose of PCI

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Most patients undergoing elective percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) erroneously believe it will extend their life or prevent myocardial infarction (MI), according to a study published online September 8, 2014, ahead of print in the BMJ.

“Coupled with the wide variability in the ways in which hospitals obtain informed consent, these findings suggest that hospital-level interventions into the structure and processes of obtaining informed consent for percutaneous coronary intervention might improve patient understanding,” write the study investigators, led by Faraz Kureshi, MD, of Saint Luke’s Mid America Heart Institute (Kansas City, MO).

 

Methods
Dr. Kureshi and colleagues performed a cross-sectional study of 991 consecutive patients with stable CAD undergoing elective PCI at 10 US academic and community hospitals between 2009 and 2011. Following the procedure, patients were asked questions to assess their perceptions of the urgency and benefits of PCI. Logistic regression models were created to examine variation in understanding across centers and operators after adjusting for patient characteristics.
Patients had a mean age of 65 years, and 75.2% were male. Approximately 44% had a previous PCI, and 85% had symptoms of chest pain or shortness of breath. Of the 135 interventional cardiologists who performed the procedures, the mean age was 50.7 years and the mean number of years in practice was 17.6.


Overly Optimistic About Benefits

Among patients surveyed, the most common perceived benefits of PCI were to extend life and prevent future MI, although other benefits were cited as well (table 1).

Table 1. Patient-Perceived Benefits of PCI

 

CAD Patients Surveyed
(n = 991) 


Extend Life

90%

Prevent MI

88%

Save Life

69%

Decrease Symptoms

67%

Improve Stress Test Abnormality

52%

One percent of patients identified symptom relief as the only benefit of treatment. The strongest patient-level predictor associated with this belief was reduction of angina (OR 0.75 for each 5-point improvement in angina score; 95% CI 0.70-0.78). Additionally, 20% of patients reported that their procedure was emergent even though all procedures included in the study were elective. 

Several patient-level characteristics were found to play roles in perception of PCI benefits. Younger patients were more likely to believe that PCI would prevent future MI, save their life, and decrease their symptoms. Married patients were more likely than those who were unmarried to think the procedure would prevent MI, and patients with less than a high school education were more likely to believe their procedure was emergent as opposed to elective. Patients with more education were more likely to think PCI would alleviate a stress test abnormality.

Among operator characteristics, only age was independently associated with patient expectations, with patients of older interventional cardiologists believing that PCI would extend their lives. 

There was wide variation across hospital sites in the process of obtaining informed consent. Responsibility for securing the consent ranged from operators to fellows to nurses depending on the center. Only 1 site included in the survey consistently provided patient educational materials for elective PCI; others reported doing so occasionally, rarely, or never.

Patient Education Falls Short 

In an accompanying editorial, Jeff Whittle, MD, of Clement J. Zablocki VA Medical Center (Milwaukee, WI), and colleagues say that while the finding that patients have overly optimistic beliefs about the benefits of PCI is not new, the inclusion of multiple hospitals shows that “patients were more likely to believe that PCI reduced mortality or the risk of myocardial infarction at some hospitals than at others, though, even where such mistaken beliefs were least likely, 4 out of 5 patients reported these as benefits.”

Despite many evidence-based approaches that could improve patients’ knowledge and understanding, the study shows that education in this area still falls short, they add. The editorial authors note that Dr. Kureshi and colleagues have previously suggested changes to the informed consent process that include personalized, explicit quantitative estimates of risks and benefits.

But Dr. Whittle and colleagues acknowledge that implementation is difficult. 

“Figuring out how to appropriately aid informed decision making across the whole of medicine—and confirming that such an effort actually has the desired effect—seems like an appropriate candidate for such implementation efforts,” they write. “We should get to work.”


Sources:
1. Kureshi F, Jones PG, Buchanan DM, et al. Variation in patients’ perceptions of elective percutaneous coronary intervention in stable coronary artery disease: cross sectional study. BMJ. 2014;Epub ahead of print.
2. Whittle J, Fyfe R, Iles RD, et al. Patients are overoptimistic about PCI: they should be equal partners in our efforts to improve understanding [editorial]. BMJ. 2014;Epub ahead of print.

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Disclosures
  • The study was supported by grants from the American Heart Association Outcomes Research Center and the National Heart, Lung, and Blood Institute.
  • Dr. Kureshi reports receiving support from the NIH.
  • Dr. Whittle reports no relevant conflicts of interest.

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