Ad Hoc PCI Outcomes Similar No Matter Who Does the Diagnostic Cath

Ad hoc PCI done by an interventional cardiologist after a noninterventional colleague performs the invasive diagnostic angiogram is an acceptable—albeit declining—practice, an analysis of the CathPCI Registry indicates.

Compared with procedures performed entirely by an interventional cardiologist—by far the more common practice today—those involving the team approach resulted in similar rates of in-hospital MACE and net adverse clinical events (NACE), according to researchers led by Fabio Lima, MD (Warren Alpert Medical School of Brown University, Providence, RI).

Though the rate of “rarely appropriate” PCI was slightly higher when noninterventional and interventional cardiologists teamed up, it was an infrequent occurrence overall (2.1% vs 1.9%), the investigators report.

The findings, published last month online in Circulation: Cardiovascular Interventions, “support current practice patterns throughout cardiac catheterization laboratories participating in [this registry],” they write.

Lima pointed out to TCTMD that the Society for Cardiovascular Angiography and Interventions (SCAI) has come out in support of rigorous oversight and quarterly reviews not just of interventional cardiologists but of all physicians operating in the cardiac cath lab—including in a 2018 consensus statement written with the Heart Failure Society of America (HFSA).

“It’s important that those hospitals that still have noninterventional cardiologists performing diagnostic cardiac catheterizations [ensure] that they’re involved in these quarterly reviews to make sure they’re performing safe and appropriate procedures on their patients,” Lima said. “I think our data has shown that fortunately they are, but it’s important that they get regular feedback.”

Commenting for TCTMD, Suresh Mulukutla, MD (UPMC Heart and Vascular Institute, Pittsburgh, PA), lead author of the SCAI/HFSA statement, said the study provides solid data that had been lacking about the outcomes of procedures in which an invasive-diagnostic cardiologist performs angiography and then passes the patient to an interventional colleague if required, which are much less common than procedures handled entirely by interventional cardiologists.

The absence of significant outcome differences between these two approaches is very encouraging, he said. “It really suggests that this is not a dangerous practice at all, and so in certain practices where this makes sense for a hospital, a cath lab, to function in this way, it seems quite appropriate to continue in that fashion.”

Team Approach Declining

At some centers, ad hoc PCI involves invasive angiography performed by a noninterventional cardiologist followed by the procedure performed by an interventionalist. “More recently, there has been a perceived reduction in this practice pattern, which is believed to be in part due to advances in complementary invasive testing methods for obstructive coronary artery disease (ie, pressure wire assessment); however, there have been no studies assessing this matter directly,” Lima et al write. Likewise, there are limited data on potential differences in outcomes based on how the initial diagnostic evaluation is conducted.

To get an idea of what has been happening around the country, the investigators turned to the CathPCI Registry, examining data on about 1.26 million patients who underwent ad hoc PCI across 1,077 sites between January 2012 and March 2018. The proportion of procedures done after an initial evaluation by an invasive-diagnostic cardiologist—as opposed to the interventional cardiologist who performed PCI—fell over time from nearly 9% to 5%. The number of noninterventional cardiologists involved in these cases also declined during the study period, with an accompanying increase in the number of solo interventionalists, although case volumes remained relatively stable for both types of physicians.

What we have to take away from that is that it’s very, very low numbers of rarely appropriate PCI. Fabio Lima

There was wide variation across centers in the proportion of ad hoc PCIs performed after an initial evaluation by an invasive-diagnostic cardiologist, with more than two-fifths of sites having no such cases; only one site performed all cases in this way.

The degree of national variation was unexpected, Lima said, but given anecdotal observations “we weren’t surprised that the numbers were dwindling over the study period and we weren’t surprised that there was an increase during the study period of solo interventional cardiologists doing more of these ad hoc PCIs on their own.”

In terms of outcomes, after adjustment, the team versus solo approach was not associated with differences in rates of MACE (1.4% vs 1.6%; adjusted OR 1.04; 95% CI 0.97-1.11) or NACE, which included MACE plus blood transfusion or any bleeding (2.8% vs 3.1%; adjusted OR 0.98; 95% CI 0.94-1.03).

“We were happy to see that patients are getting safe procedures and having good outcomes regardless if it’s the team approach or the solo interventionalist,” Lima said.

The rate of “rarely appropriate” PCI was slightly higher when noninterventional and interventional cardiologists worked together, even after adjustment, although whether the difference is clinically meaningful is less clear. Reducing the rate by 0.2% with noninterventional/interventional cardiologist teams would avoid just four “rarely appropriate” procedures out of nearly 1.3 million PCIs performed in this study, the investigators note.

“I think fortunately what we have to take away from that is that it’s very, very low numbers of rarely appropriate PCI,” Lima said, adding, however, that why this difference might exist still requires additional study.

Mulukutla agreed that further investigation of the finding is warranted, but also noted that overall numbers are low. “The invasive-diagnostic cardiologists may have a slightly higher rate of ‘rarely appropriate’ PCI because they’re not thinking about the interventional appropriateness on every single patient like the solo interventionalist does,” he suggested. But, he added, “I don’t think that this manuscript suggests that there’s something amiss or something problematic about it.”