SCAI Contributes List of Top 5 Interventional Cardiology Procedures to Avoid
The Society for Cardiovascular Angiography and Interventions (SCAI) has created a list of 5 tests and treatments that should be avoided in patients with cardiovascular disease. The list, released in a statement on March 31, 2014, was developed as part of the American Board of Internal Medicine Foundation’s Choosing Wisely initiative.
According to the SCAI statement, which was developed by members of the SCAI Quality Improvement Committee, the tests and procedures that appear “in this Choosing Wisely list were selected from among the scenarios rated as inappropriate (or rarely appropriate) by the appropriate use criteria (AUC) or as Class III (not recommended) by the guidelines.”
Therefore, the advice is not likely to be controversial, SCAI vice president James C. Blankenship, MD, of Geisinger Medical Center (Danville, PA), told TCTMD in a telephone interview.
“One caveat,” he said, “is that the guidelines are often written with very careful wording, and sometimes they are complex with enough qualifiers and modifiers to be somewhat confusing.… The goal of [this list] is to provide clarity, so that the primary care doctor who doesn’t necessarily know much about cardiology should be able to understand what we’re talking about.”
Another major audience is patients, Dr. Blankenship added. “These are meant to stimulate discussion between the patient and physician.”
Emphasis on Testing, Treatment without Symptoms
As outlined on SCAI’s website, the 5 recommendations suggest avoiding:
- Routine stress testing after PCI without specific clinical indications
- Coronary angiography in post-CABG and post-PCI patients who are asymptomatic, or who have normal or mildly abnormal stress tests and stable symptoms not limiting quality of life
- Coronary angiography for risk assessment in patients with stable ischemic heart disease who are unwilling to undergo revascularization or are not candidates for revascularization based on comorbidities or individual preferences
- Coronary angiography to assess risk in asymptomatic patients with no evidence of ischemia or other abnormalities on adequate noninvasive testing
- PCI in asymptomatic patients with stable ischemic heart disease without the demonstration of ischemia on adequate stress testing or with abnormal FFR testing
Routine stress testing after PCI and coronary angiography after PCI or CABG should generally be limited to patients with changes in clinical status, the statement notes. The document also specifies that exceptions to the rule against PCI in patients with stable but asymptomatic disease without evidence of ischemia include a significant lesion in the LAD or greater than 90% proximal lesion in a major coronary artery.
A Step in the Right Direction
Also in a telephone interview, Rita F. Redberg, MD, MSc, of the University of California, San Francisco (San Francisco, CA), told TCTMD that the Choosing Wisely campaign “has had a big impact. It certainly got people thinking about what we are doing too much of and what we can do better. It was professional society-led, so that was particularly advantageous.”
While noting that Choosing Wisely is a step in the right direction and praising the SCAI leadership for taking part, she emphasized that “ideally the evidence base and whole process should be a bit more transparent and public.” Dr. Redberg co-wrote an editorial published online February 17, 2014, ahead of print in JAMA: Internal Medicine raising those exact issues in relation to a top-five list for emergency medicine.
But some of the advice on SCAI’s list involves too many “qualifiers,” Dr. Redberg added, citing the recommendation against PCI in asymptomatic patients without evidence of ischemia. “I think you could have stopped [the sentence] after ‘asymptomatic patients,’” she suggested. “I don’t know why we would be doing PCI in asymptomatic patients, period. Because the benefits are possibly only for symptoms and we know that 30% or more of people getting PCI for stable coronary disease are asymptomatic, according to the [National Cardiovascular Data Registry].”
Dr. Redberg concluded, “As Choosing Wisely evolves, we’re really looking for recommendations that one could actually measure. But it’s a good start, and I hope they won’t stop here.”
Looking at the Big Picture
Similarly, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), told TCTMD in a telephone interview that, while the 5 recommendations are valid and address “pretty common” scenarios, more needs to be done. He stressed that interventionalists should lean toward “global assessments of the goals of care” in treating their patients, noting, “Quality improvement is a continuous process.”
The SCAI statement, he said, “just codifies a philosophy that many of us in the interventional community feel very strongly about now. That is, while we can benefit patients with what we do, we have to do things for the right reasons.”
“Like the AUC, one cannot look at all of these as hard and fast rules [that apply] 100 percent of the time. There are going to be clinical scenarios where a clinician might feel that someone is sufficiently high-risk and could merit routine stress testing. Or one might do diagnostic angiography [in someone with stable disease originally unwilling to undergo PCI] because the patient and family might change their minds based upon risk features [after] the angiogram,” Dr. Kirtane said, adding, “As a general rule, though, the Choosing Wisely recommendations make sense and are typically supported by data.”
Though some of the recommendations do not directly involve interventions, they are still relevant to interventionalists, he said, stressing that pre- and post-procedure care is as important as what happens in the cath lab.
“We know that testing for these types of indications leads to downstream utilization of procedures, and oftentimes if that testing is done, we then become the gatekeepers in the cath lab,” Dr. Kirtane explained. “So in a sense, some of these reflect the integration of care from the outpatient to the inpatient setting, and emphasize that we as interventionalists have to be very cognizant of what’s going on screening-wise that gets people into the cath lab.”
Society for Cardiovascular Angiography and Interventions. As part of Choosing Wisely campaign: SCAI issues list of tests and treatments to avoid [press release]. http://www.scai.org/Press/detail.aspx?cid=08645251-d4c1-4b35-978d-444c0654714e#.Uz2pfKKiIpp. Published March 31, 2014. Accessed April 4, 2014.
- Dr. Blankenship reports serving as a site primary investigator for industry-funded multicenter trials.
- Dr. Redberg reports no relevant conflicts of interest.
- Dr. Kirtane reports serving as a reviewer of the SCAI statement.