Misperceptions Persist Regarding ‘Inappropriate’ PCI
San Francisco, CA—Changing nomenclature could begin to change notion that huge numbers of PCIs are unnecessary.
Appropriate use criteria (AUC) for revascularization are commonly misunderstood by people outside of interventional cardiology, leading to the perception that an enormous number of procedures performed are unnecessary.
Amidst consistent debate about which procedures are actually necessary, “One thing is incontrovertible: PCI can reduce symptoms compared to medical therapy,” said Ajay Kirtane, MD, of Columbia University Medical Center in New York, at TCT 2013 on Wednesday. But there is still a consistent issue made of the underuse of medical therapy prior to going straight to stent implantation. Just this week an article in Bloomberg News cited data that about 74% of patients try “fewer than two heart medications” before moving to a procedure, a statistic Kirtane called a “blatant misrepresentation of the facts.” The term “heart medications” alludes specifically to anti-anginal medications, and thus is not including standard therapies like statins, aspirin and others.
Further, anti-anginal medications can improve symptoms in many patients, but Kirtane pointed out that virtually no such agents have demonstrated benefits with regard to “the hard outcomes, the things we’re trying to prevent for stable patients.”
Among the sources of this controversy is the nomenclature used in the AUC, which rates a number of patient scenarios as appropriate, uncertain or inappropriate for PCI. This is a problem for the lay public, Kirtane said: “The word ‘inappropriate’ per these ratings is not the same word ‘inappropriate’ that we use in common English.” There are certainly cases, he said, where the rating would be ‘inappropriate,’ but there may be ample medical reason to perform the revascularization procedure. As former American College of Cardiology president Ralph Brindis, MD, of the University of California, San Francisco, said in 2010 at an FDA hearing, “Just because it’s [rated as] ‘inappropriate’ doesn’t mean it’s not medically indicated.” This is poorly understood, however, leading to claims that billions of dollars are being spent on completely unnecessary procedures.
There is also substantial variability even within those AUC ratings. A survey published in the Journal of the American College of Cardiology in 2011 found that three out of the 10 scenarios commonly rated as inappropriate were no longer judged as inappropriate, further confounding this issue. In registry data so far, there also has been no link shown between appropriateness criteria and clinical outcomes.
To address this misunderstanding, the AUC nomenclature was recently changed, so that “uncertain” is now “may be appropriate” and “inappropriate” is “rarely appropriate.” There have been accusations that this amounts to “gilding the lily,” but Kirtane said it is far from just a semantic change. “If you remove the requisite assumption of harm from the colloquial connotation of ‘inappropriate,’ that’s important for patients,” he said, adding that following these types of guidelines will save money in the long run. “Do the right thing for the patient, and I think if you do that you’re ultimately going to effect the best outcomes.”
Kirtane reports serving on the writing committee of the AUC for Diagnostic Catheterization, which received funding from a number of manufacturers.