How appropriate is coronary intervention?

When is a PCI procedure “appropriate” and when is it not?  The answer depends on how you define “appropriate”, and recently appropriate use criteria for coronary revascularisations have been jointly developed by six professional organisations, including the AHA and ACC.  The aim of this study, therefore, was to assess the appropriateness of PCI in the Unites States according to these new criteria.

The patient population studied was those undergoing PCI between July 2009 and September 2010 at 1091 US hospitals.  All data were acquired from the National Cardiovascular Data Registry.  Results were then stratified by whether the procedure was performed for STEMI, NSTEMI, or a nonacute indication.  The main outcome measure was the proportion of acute and nonacute PCIs classified as appropriate, inappropriate, or uncertain.

500,154 PCI procedures were studied, the vast majority (71.1%) being for acute indications.  For acute indications, 98.6% of PCIs were found to be appropriate, however only 50.4% of nonacute PCIs were deemed appropriate; a further 38% were labelled as “uncertain” and 11.6% as inappropriate.  Reasons for inappropriate PCI included no clinical history of angina (53.8%), low-risk ischaemia or non-invasive testing (71.6%), or suboptimal antianginal therapy (95.8%).  Substantial hospital variation for nonacute procedures was seen.

Conclusions:

In this study of US practice, nearly all acute PCIs were appropriate, whereas it appears that many nonacute PCIs were inappropriate.  Further research into why inappropriate procedures take place is warranted.

  • Chan PS, Pater MR, Klein LW et al.  Appropriateness of Percutaneous Coronary Intervention.  JAMA 2011:306;53-61.