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Informed Decision Making for Percutaneous Coronary Intervention for Stable Coronary Disease

10 Sep, 15 | by flee

Prior studies suggest patients are often misinformed about the anticipated benefits of PCI for stable coronary disease.  However, there is little data on patient-provider discussions that may explain discrepancies in patient understanding about the limited benefits of PCI in this setting.   Rothberg and colleagues performed a cross-sectional analysis of 59 conversations between providers and patients about PCI.  The conversations included 23 cardiologists (all male, 6 interventionalists, median 19 years experience) representing all regions of the United States from 2008 to 2012.  Conversations were analyzed for discussion of 7 elements central to shared-decision making: more…

Precision Medicine to Reduce Bleeding with PCI   

5 May, 15 | by Alistair Lindsay


Periprocedural bleeding remains one of the most common adverse events after percutaneous coronary intervention (PCI) and is associated with increased mortality.  Although strategies to minimize PCI bleeding have been identified, these strategies are infrequently applied to patients at highest bleeding risk.  Using a pre-post study design, Spertus et al. evaluated the impact of assessing individual patient bleeding risk from validated models and providing this bleeding risk estimate in personalized informed consent documents for PCI.  The intent of the intervention was to increase the procedural team’s awareness of patients at low, moderate, and risk for PCI related bleeding and thereby influence the use of bleeding avoidance strategies (i.e. bivalirudin, radial access, and vascular closure devices) and reduce periprocedural bleeding events.  more…

Second-generation stents fail to BEST CABG

16 Apr, 15 | by Alistair Lindsay

The technology of drug eluting stents for percutaneous coronary intervention (PCI) has improved over time with resultant improvements in patient outcomes.  Although prior studies have demonstrated the benefit of surgical coronary artery bypass grafting (CABG) over transcatheter PCI among patients with multivessel coronary artery disease (CAD), these studies did not incorporate newer generation drug-eluting stents.  The multicenter BEST trial randomized 880 patients with multivessel CAD to PCI with an everolimus-eluting stent or to CABG. The primary end point for this non-inferiority study was a composite of death, myocardial infarction, or target-vessel revascularization at 2 years.  The results of the study non-significantly favored CABG at 2 years of follow-up with the primary end-point occurring in 7.9% of the CABG group and 11% of the PCI group.  more…

Risks and Benefits of Percutaneous Coronary Interventions in Stable Coronary Disease: A Qualitative Analysis of Cardiologists’ Bedside Discussions  

20 Dec, 14 | by Alistair Lindsay

Although the benefits of PCI for stable CAD are limited to symptom reduction, prior studies have shown that patients often believe PCI for stable coronary artery disease (CAD) will mitigate the future risks of myocardial infarction or death. This study examined discussions between cardiologists and patients regarding angiograms and PCI in stable CAD to identify potential areas of misperception. Qualitative content analysis was performed on transcripts created from recordings of 40 patient-provider encounters with cardiologists participating in the Verilogue Point-of-Practice Database. Physician-patient encounters were coded for five major categories and subcategories that may explain patients’ perceptions of PCI benefit including the rationale for recommending the procedure, a discussion of benefits, a discussion of risks, provider communication style, and patients and family members contributions to the discussion. more…

Dual Antiplatelet Therapy Beyond 1-year after Percutaneous Coronary Interventions for Stable Coronary Artery Disease Results in Harm  

20 Dec, 14 | by Alistair Lindsay

The benefit of extended dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is uncertain. The ARTIC-Interruption Trial examined discontinuation of DAPT at 1-year after PCI vs continuation for an additional 6-18 months. The study randomized patients 1-year after PCI to continuation (N=635) or interruption (N=624) groups, and examined the primary composite endpoint of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization over a median follow-up of 17 months. No significant differences were observed between the treatment groups for the primary outcome (hazard ratio [HR] 1.17; 95% confidence interval [CI] 0.68–2.03]; p=0.58). Bleeding events (as defined by STEEPLE criteria) occurred significantly more frequently in the continuation group (HR 0.26; 95% CI 0.07–0.91; p=0.04) when major and minor bleeding events were combined. As this study was a follow on to an evaluation of antiplatelet regimens guided by platelet reactivity at the time of index PCI, there was variation in the type of DAPT between patients at randomization for this study. Furthermore, there was crossover between treatment arms that was not evaluated with an on-treatment analysis. more…

No benefit to thrombus aspiration in STEMI

14 Oct, 14 | by Alistair Lindsay

Thrombus aspiration in acute ST-segment elevation myocardial infarction (STEMI) is clinically appealing and often used prior to PCI. However, the majority of trials evaluating thrombus aspiration have failed to demonstrate significant mortality benefit. The Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia (TASTE) trial is a multi-center study that randomized a total of 7244 presenting with a STEMI for primary PCI to either thrombus aspiration or PCI without prior aspiration. From this trial, the authors have previously reported no significant mortality difference at 30 days between routine thrombus aspiration and standard PCI. more…

Patient Understanding of Elective PCI Benefit Varies by Hospital  

14 Oct, 14 | by Alistair Lindsay

Elective percutaneous coronary intervention (PCI) does not prevent mortality or myocardial infarction, but is an important therapy for the relief of ischemic symptoms.   However, a majority of patients believe that PCI for stable coronary artery disease (CAD) will prolong their lives and prevent heart attacks. In this study, investigators surveyed 991 patients undergoing elective PCI for stable CAD at 10 hospitals to assess patient perceptions about the procedure and determine if patient understanding of procedural benefit was associated with the PCI operator or the hospital. Patients believed that their elective PCI was emergent in 20% of cases, 90% of patients felt that the PCI would prolong their life, and 88% felt that elective PCI would prevent future heart attacks, while only 1% correctly identified symptom improvement as the primary benefit of the procedure. Patient beliefs about the benefits of elective PCI varied at the hospital level, but similar variation was not observed across operators within sites. more…

No Benefit from Extended Dual Anti-Platelet Therapy?

2 Feb, 14 | by Alistair Lindsay

The PARIS (patterns of non-adherence to anti-platelet regimens in stented patients) registry is a prospective observational study of patients from the US and Europe who were discharged on dual anti-platelet therapy (DAPT) following coronary stenting. Among 5018 patients from this registry, the rates of physician recommended discontinuation, brief interruption (i.e. for surgery), or disruption (ie non-compliance, bleeding) of DAPT was assessed over 2 years. The observed rate of discontinuation was 40.8%, interruption 10.5,%, and the rate of DAPT disruption was 14.4%. Patients with DAPT disruption were at significantly increased risk for major cardiovascular events compared with patients on DAPT (hazard ratio 1.50, 95% CI 1.14 – 1.97), with highest risk in the first 7 days of disruption (hazard ratio 7.04, 95% CI 3.31 – 14.95). In contrast, there was a lower risk for major adverse cardiovascular events among patients who had DAPT discontinued in comparison to patients who remained on DAPT (hazard ratio 0.63, 95% CI 0.46 – 0.86). more…

Stent type and interrupted anti-platelet therapy does not correlate with adverse events after non-cardiac surgeries

29 Dec, 13 | by Alistair Lindsay

Guidelines recommend delaying elective surgery in patients with drug eluting stent (DES) for one year after stent implantation to allow completion of 1 year of dual anti-platelet therapy (DAPT) without interruption.  This recommendation is based on expert consensus and results in several clinical questions, including whether it is preferable to use a bare metal stent (BMS) in patients with a potential for future surgery and whether this delay is excessive for patients considering surgery with other potential benefits (i.e. knee replacement in patients with life-limiting osteoarthritis).  Accordingly, the authors sought to understand the risk of major adverse cardiovascular events (MACE) following non-cardiac surgery among patients with coronary stents as a function of time since coronary stenting, stent type, and antiplatelet therapy during surgery. more…

Bivalirudin in contemporary STEMI treatment

29 Dec, 13 | by Alistair Lindsay

The novel direct thrombin inhibitor bivalirudin is now widely used as an adjunctive therapy in patients undergoing primary PCI for ST elevation myocardial infarction (STEMI). This stems from trial data demonstrating bivalirudin results in lower bleeding rates and better long term survival as compared with the combination of heparin and a GP IIb/IIIa inhibitor. However, clinical practice has subsequently changed, including greater use of radial access with resultant lower bleeding risk and expanded use of newer generation P2Y­12 inhibitors.  The EUROMAX trial sought to understand whether use of bivalirudin benefits patients in light of these changes in clinical practices. more…

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