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Kodeboina M, Piayda K, Jenniskens I, Vyas P, Chen S, Pesigan RJ, Ferko N, Patel BP, Dobrin A, Habib J, Franke J. Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095633. [PMID: 37174152 PMCID: PMC10177939 DOI: 10.3390/ijerph20095633] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/24/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.
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Affiliation(s)
- Monika Kodeboina
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Clinic for Internal Medicine and Cardiology, Marien Hospital, 52066 Aachen, Germany
| | - Kerstin Piayda
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Department of Cardiology and Vascular Medicine, Medical Faculty, Justus-Liebig-University Giessen, 35392 Giessen, Germany
| | | | | | | | | | | | | | | | | | - Jennifer Franke
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Philips Chief Medical Office, 22335 Hamburg, Germany
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2
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Struja T, Suter F, Rohrmann S, Koch D, Mueller B, Schuetz P, Kutz A. Comparison of Cardiovascular Procedure Rates in Patients With Supplementary vs Basic Insurance in Switzerland. JAMA Netw Open 2023; 6:e2251965. [PMID: 36662521 PMCID: PMC9860525 DOI: 10.1001/jamanetworkopen.2022.51965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/28/2022] [Indexed: 01/21/2023] Open
Abstract
Importance Switzerland's mandatory health insurance provides universal coverage, but residents can opt for supplementary private insurance for nonessential, nonvital amenities. It is debated whether people with supplementary private insurance receive overtreatment due to financial incentives. Objective To assess whether incidence rates of cardiovascular procedures in people with supplementary private insurance are higher than in those with basic insurance only. Design, Setting, and Participants A population-based weighted cohort comparative effectiveness study, using administrative claims data from Switzerland assessing incidence rates (IRs), was conducted in adults undergoing a nonemergency cardiovascular inpatient procedure from January 1, 2012, to December 31, 2020. Analysis included primary or secondary discharge procedure codes for 1 of the following: percutaneous transluminal coronary angioplasty (PTCA), left atrial appendage (LAA) occlusion, patent foramen ovale (PFO) closure, transcatheter aortic valve replacement (TAVR), mitral valve clip implantation, cardiac pacemaker implantation, and atrial fibrillation/atrial flutter ablation. Exposures Supplementary private health insurance. Main Outcomes and Measures Incidence rates of cardiovascular procedures between insurance groups calculated by negative binomial regression adjusted by inverse probability weights. Results Of 590 919 admissions (median age, 68 years; IQR, 57-77 years), 55.5% male, 15.7% non-Swiss nationality), 70.1% had basic insurance only. Independent of insurance status, IR for all cardiovascular procedures steadily increased over the study years. In general, people with supplementary private insurance received cardiovascular procedures more frequently (IR ratio [IRR], 1.11; 99% CI, 1.10-1.11) than people with basic insurance only. There was also an increase for every procedure: PTCA (IRR, 1.12; 99% CI, 1.12-1.13), LAA closure (IRR, 1.15; 99% CI, 1.13-1.16), mitral valve clip implantation (IRR, 1.08; 99% CI, 1.07-1.09), TAVR (IRR, 1.04; 99% CI, 1.03-1.06), PFO closure (IRR, 1.01; 99% CI, 1.00-1.02), pacemaker implantation (IRR, 1.08; 99% CI, 1.07-1.09), and atrial fibrillation/atrial flutter ablation (IRR, 1.12; 99% CI, 1.11-1.12). Sensitivity analyses, including side procedures, stratification by length of stay, and propensity score matching, suggested robustness of the results. Conclusions and Relevance This study found an association between supplementary private insurance and a higher likelihood of receiving nonemergency cardiovascular procedures. Whether this higher rate of procedures in people with supplementary private insurance is based on clinical reasoning or due to financial incentives warrants further exploration.
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Affiliation(s)
- Tristan Struja
- Medical University Clinic, Division of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
- Massachusetts Institute of Technology, Institute for Medical Engineering and Science, Cambridge, Massachusetts
| | - Flurina Suter
- Division of Chronic Disease Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Sabine Rohrmann
- Division of Chronic Disease Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Daniel Koch
- Medical University Clinic, Division of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Medical University Clinic, Division of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
- Medical Faculty of the University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Clinic, Division of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
- Medical Faculty of the University of Basel, Basel, Switzerland
| | - Alexander Kutz
- Medical University Clinic, Division of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Nelson AJ, Inohara T, Rao SV, Kaltenbach LA, Wojdyla D, Wang TY. Comparing the Classification of Percutaneous Coronary Interventions Using the 2012 and 2017 Appropriate Use Criteria: Insights From 245,196 Patients in the NCDR CathPCI Registry. Am Heart J 2023; 255:117-124. [PMID: 36220357 DOI: 10.1016/j.ahj.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/26/2022] [Accepted: 10/01/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Appropriate use criteria (AUC) have been developed to promote the rational use of percutaneous coronary intervention (PCI) among clinicians and to provide benchmarking feedback to hospitals. The original AUC were published in 2012 and subsequently updated in 2017 to reflect emerging, contemporary evidence however the degree to which the updated guidance re-classifies PCI appropriateness is unknown. METHODS Elective PCI cases from March 1, 2018 until June 30, 2021 were identified from within the NCDR CathPCI database. PCI cases were classified as 'appropriate,' 'uncertain' or 'inappropriate' under 2012 AUC and 'appropriate,' 'may be appropriate' or 'rarely appropriate' under 2017 AUC; those with missing data elements were termed 'not mappable.' Groups that 'remained appropriate' (appropriate in both 2012 and 2017), 'became non-appropriate' ('appropriate' in 2012 but became either 'may be appropriate' or 'rarely appropriate in 2017) and 'became appropriate' ('appropriate' in 2017 but were 'uncertain' or 'inappropriate' in 2012) were descriptively compared. Concordance was assessed by calculation of Cohen's Kappa. RESULTS A total of 245,196 patients underwent elective PCI across 1669 centers. By 2012 AUC, 44% were classified 'appropriate,' 28% were 'uncertain' and 16% were 'inappropriate' compared with 2017 AUC which considered 34% 'appropriate', 56% may be 'appropriate' and 4% 'rarely appropriate'. Overall fair agreement was observed with a Kappa statistic of 0.40 (95%CI 0.396-0.403). Compared with PCI that 'remained appropriate' under the 2017 AUC, PCI that 'became non-appropriate' in 2017 were more likely to be asymptomatic, less likely to be on anti-anginals and less likely to have complex lesions. Compared with PCI that 'became non-appropriate', PCI that 'became appropriate' had a higher proportion of atypical and non-anginal symptoms and were less likely to have had positive functional tests. Procedural related outcomes were similar across all groups. A total of 29 429 PCI (12.0%) were not mappable by 2012 AUC while 16 077 (6.6%) were not mappable by 2017 AUC. CONCLUSIONS In this contemporary analysis of patients undergoing PCI in the United States, only fair agreement between the 2012 and updated 2017 AUC was observed. While some of this reflects the intention of the updated guidance, the large proportion that were considered 'maybe appropriate' or who 'became non-appropriate' reflect the difficulties of documenting and implementing contemporary AUC guidance.
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Affiliation(s)
- Adam J Nelson
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Taku Inohara
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Sunil V Rao
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Lisa A Kaltenbach
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Daniel Wojdyla
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Tracy Y Wang
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Harris E, Conway D, Jimenez-Aranda A, Butts J, Hedley-Takhar P, Thomson R, Astin F. Development and user-testing of a digital patient decision aid to facilitate shared decision-making for people with stable angina. BMC Med Inform Decis Mak 2022; 22:143. [PMID: 35624456 PMCID: PMC9137092 DOI: 10.1186/s12911-022-01882-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
Background Research shows that people with stable angina need decision support when considering elective treatments. Initial treatment is with medicines but patients may gain further benefit with invasive percutaneous coronary intervention (PCI). Choosing between these treatments can be challenging for patients because both confer similar benefits but have different risks. Patient decision aids (PtDAs) are evidence-based interventions that support shared decision-making (SDM) when making healthcare decisions. This study aimed to develop and user-test a digital patient decision aid (CONNECT) to facilitate SDM for people with stable angina considering invasive treatment with elective PCI. Methods A multi-phase study was conducted to develop and test CONNECT (COroNary aNgioplasty dECision Tool) using approaches recommended by the International Patient Decision Aid Standards Collaboration: (i) Steering Group assembled, (ii) review of clinical guidance, (iii) co-design workshops with patients and cardiology health professionals, (iv) first prototype developed and ‘alpha’ tested (semi-structured cognitive interviews and 12-item acceptability questionnaire) with patients, cardiologists and cardiac nurses, recruited from two hospitals in Northern England, and (v) final PtDA refined following iterative user-feedback. Quantitative data were analysed descriptively and qualitative data from the interviews analysed using deductive content analysis. Results CONNECT was developed and user-tested with 34 patients and 29 cardiology health professionals. Findings showed that CONNECT was generally acceptable, usable, comprehensible, and desirable. Participants suggested that CONNECT had the potential to improve care quality by personalising consultations and facilitating SDM and informed consent. Patient safety may be improved as CONNECT includes questions about symptom burden which can identify asymptomatic patients unlikely to benefit from PCI, as well as those who may need to be fast tracked because of worsening symptoms. Conclusions CONNECT is the first digital PtDA for people with stable angina considering elective PCI, developed in the UK using recommended processes and fulfilling international quality criteria. CONNECT shows promise as an approach to facilitate SDM and should be evaluated in a clinical trial. Further work is required to standardise the provision of probabilistic risk information for people considering elective PCI and to understand how CONNECT can be accessible to underserved communities. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01882-x.
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Affiliation(s)
- Emma Harris
- Centre for Applied Research in Health, School of Human and Health Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
| | - Dwayne Conway
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Angel Jimenez-Aranda
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,NIHR Devices for Dignity MedTech Co-Operative, Sheffield, UK
| | - Jeremy Butts
- Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
| | - Philippa Hedley-Takhar
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,NIHR Devices for Dignity MedTech Co-Operative, Sheffield, UK
| | - Richard Thomson
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Felicity Astin
- Centre for Applied Research in Health, School of Human and Health Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK. .,Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK.
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Kini V, Breathett K, Groeneveld PW, Ho PM, Nallamothu BK, Peterson PN, Rush P, Wang TY, Zeitler EP, Borden WB. Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2022; 15:e000105. [PMID: 35189687 PMCID: PMC9909614 DOI: 10.1161/hcq.0000000000000105] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Low-value health care services that provide little or no benefit to patients are common, potentially harmful, and costly. Nearly half of the patients in the United States will receive at least 1 low-value test or procedure annually, creating risk of avoidable complications from subsequent cascades of care and excess costs to patients and society. Reducing low-value care is of particular importance to cardiovascular health given the high prevalence and costs of cardiovascular disease in the United States. This scientific statement describes the current scope and impact of low-value cardiovascular care; reviews existing literature on patient-, clinician-, health system-, payer-, and policy-level interventions to reduce low-value care; proposes solutions to achieve meaningful and equitable reductions in low-value care; and suggests areas for future research priorities.
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Orsini E, Marzilli M, Zito GB, Carbone V, Latina L, Oliviero U, Rizzo U. Clinical outcomes of newly diagnosed, stable angina patients managed according to current guidelines. The ARCA (Arca Registry for Chronic Angina) Registry: A prospective, observational, nationwide study. Int J Cardiol 2022; 352:9-18. [PMID: 35120946 DOI: 10.1016/j.ijcard.2022.01.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Clinical outcomes of stable angina patients treated according to guidelines recommendations (medical therapy first, selective revascularization in high risk or unresponsive patients) are not fully known. METHODS AND RESULTS Eight hundred thirty-three patients with newly diagnosed, stable angina were enrolled in a prospective, observational, nationwide registry and followed for 1 year. Symptoms and quality of life were evaluated with the CCS angina grading, with a self-assessment scale and with the SAQ-7. A composite end-point of MACEs (all-cause death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for unstable angina) at 1 year was considered. Upon enrollment, all patients were prescribed guidelines directed medical therapy. After one month of therapy, angina relieved or improved in 47% of the overall population. Patients in CCS class I significantly increased from 28.4% at enrollment to 67.1% at 12 months, and the SAQ-7 score from 58.4 ± 20 to 85.9 ± 14. The rate of MACEs was low (2.9%) in the overall population. After one month of medical therapy, 40.6% of patients were referred for coronary angiography and revascularization for resistant symptoms (invasive strategy). Among these, 38.2% had normal coronary arteries and 47% actually underwent revascularization. No difference between invasive and medical groups was found at 12 months in symptoms, quality of life and MACEs, except for a greater improvement in self-assessed symptoms in the invasive group. Combined medical and invasive strategies left 28.5% of patients still symptomatic at the end of the study. CONCLUSIONS The study confirms the efficacy and safety of a tailored approach to stable angina, as recommended by guidelines, with medical therapy first followed by selective revascularization when needed.
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Affiliation(s)
- Enrico Orsini
- University Division of Cardiology, Cardiothoracic and Vascular Department, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy.
| | - Mario Marzilli
- Department of Surgery, Medical, Molecular and Critical Area Pathology, University of Pisa, Italy
| | | | - Vincenzo Carbone
- Outpatient Cardiology, ASL Napoli 3 Sud, ARCA Campania, Napoli, Italy
| | - Loredana Latina
- Center for the Prevention of Cardiovascular Disease, ARCA Trentino Alto Adige, Bolzano, Italy
| | - Ugo Oliviero
- Department of Translational Medical Sciences, University Federico II, ARCA Campania, Napoli, Italy
| | - Umberto Rizzo
- Outpatient Cardiology, ASL Bari, ARCA Puglia, Bari, Italy
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7
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Kumar A, Doshi R, Khan SU, Shariff M, Baby J, Majmundar M, Kanaa'N A, Hedrick DP, Puri R, Reed G, Mehran R, Kapadia S, Khot UN, Kalra A. Revascularization or optimal medical therapy for stable ischemic heart disease: A Bayesian meta-analysis of contemporary trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:42-47. [PMID: 35210188 DOI: 10.1016/j.carrev.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/04/2021] [Accepted: 12/06/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The role of revascularization in patients with stable ischemic heart disease (SIHD) has been controversial, more so in the present era of drug-eluting stents. AIMS To examine the absolute risk difference (ARD) between revascularization plus optimal medical therapy (OMT) versus OMT alone among patients with SIHD using Bayesian approach. METHODS PubMed/MEDLINE and Cochrane citation indices were utilized to identify randomized controlled trials (RCTs) through March 31, 2020. Among trials comparing initial revascularization plus OMT with initial OMT alone, revascularization arm must have comprised >50% of patients receiving either percutaneous or surgical revascularization, and >50% of patients must have received aspirin and statin as OMT in both arms. RESULTS Seven RCTs (12,494) were included in the final analysis. The ARD of all-cause mortality for revascularization with respect to OMT was centred at -0.002 (95% CrI: -0.01; 0.01, Tau: 0.01, 67% probability of ARD of revascularization vs. OMT < 0). The ARD for cardiac mortality was centred at -0.0025 (95%CrI: -0.01; 0.01, Tau: 0.01, 77% probability of ARD of revascularization vs. OMT < 0). The ARD for MI was -0.02 (95% CrI: -0.06; 0.00, Tau: 0.02, 97% probability of ARD for revascularization vs. OMT < 0). There was 96% probability of ARD for unstable angina with revascularization vs. OMT < 0, 4.5% probability of ARD for freedom from angina with revascularization vs. OMT < 0, and 6% probability of ARD for stroke with revascularization vs. OMT < 0. CONCLUSIONS Bayesian analysis demonstrated minimal probability of difference in all-cause mortality and cardiac mortality in patients with SIHD who underwent revascularization compared with OMT alone. However, revascularization was associated with lower probability of MI, unstable angina, and increased freedom from angina, but a higher risk of stroke compared with OMT alone. PROSPERO The protocol of this systematic review and meta-analysis was registered in PROSPERO [CRD42020160540].
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Affiliation(s)
- Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Rajkumar Doshi
- Department of Cardiology, St. Joseph's Medical Centre, Paterson, NJ, USA
| | - Safi U Khan
- Department of Internal Medicine, West Virginia University, Morgantown, WV, USA
| | - Mariam Shariff
- Department of General Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jeswin Baby
- Division of Epidemiology and Biostatistics, St John's Research Institute, Bangalore, India; Department of Statistical Sciences, Kannur University, Kerala, India
| | - Monil Majmundar
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, NYC, USA
| | - Anmar Kanaa'N
- Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA
| | - David P Hedrick
- Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Grant Reed
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Umesh N Khot
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ankur Kalra
- Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
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Guduguntla V, Redberg RF. Popular procedures without evidence of benefit: A case study of percutaneous coronary intervention for stable coronary artery disease. Eur J Intern Med 2021; 94:15-21. [PMID: 34535375 DOI: 10.1016/j.ejim.2021.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 01/09/2023]
Abstract
Despite limited benefit, percutaneous coronary intervention (PCI) remains a common procedure that is often performed for uncertain or inappropriate indications in patients with stable coronary artery disease (CAD). PCI cases per capita have increased year-over-year in most European countries, and many have higher rates than the U.S. Meanwhile, first-line therapy such as optimal medical therapy (OMT) and lifestyle changes, continue to be under-utilized. This article reviews the evidence on use of PCI in stable CAD. Specifically, we analyzed randomized control trials, systematic reviews, appropriate use criteria, and professional society guidelines that examine the risks and benefits of PCI compared to OMT. We then highlight utilization patterns as well as interventions that better align current practice with evidence-based care.
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Affiliation(s)
- Vinay Guduguntla
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94131, United States.
| | - Rita F Redberg
- Department of Cardiology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94131, United States
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9
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Chatterjee S, Fanaroff AC, Parzynski C, Curtis J, Kolansky DM, Maddox TM, Mukherjee D, Yeh RW, Giri J. Comparison of Patients Undergoing Percutaneous Coronary Intervention in Contemporary U.S. Practice With ISCHEMIA Trial Population. JACC Cardiovasc Interv 2021; 14:2344-2349. [PMID: 34736733 DOI: 10.1016/j.jcin.2021.08.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/19/2021] [Accepted: 08/03/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The study sought to assess the proportion of patients in modern U.S. interventional practice that fulfilled criteria for enrollment in the ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial. BACKGROUND The ISCHEMIA trial, which enrolled patients with stable ischemic heart disease (SIHD), showed that revascularization improved angina symptoms with little effect on death or myocardial infarction. METHODS A cross-sectional analysis of the National Cardiovascular Data Registry CathPCI Registry (v5.0), including 1,662 hospitals, was performed. Patients undergoing percutaneous coronary intervention (PCI) for SIHD in routine clinical practice meeting ISCHEMIA trial inclusion criteria and those that did not were evaluated. RESULTS During the study period, 388,212 patients underwent PCI for SIHD, comprising 41.88% of all patients undergoing PCI during the study period. Of these, 125,302 (32.28%; 13.52% of all patients undergoing PCI) met criteria for enrollment in the ISCHEMIA trial. Among SIHD patients that did not meet criteria, 71,852 (18.51%) had SIHD with high-risk features (35.2% left main disease, 43.7% left ventricular systolic dysfunction, 16.8% end-stage renal disease), 67,159 (17.3%) had SIHD with negative or low-risk functional testing, and 123,899 (31.92%) either had no stress testing or did not have ischemic burden reported. At the median hospital, 32.1% (interquartile range: 23.5%-40.6%) of SIHD patients met criteria for enrollment in the ISCHEMIA trial, with these patients experiencing lower unadjusted in-hospital mortality rate than comparator groups who met exclusion criteria for the trial (0.11%) (P < 0.01 for all comparisons). CONCLUSIONS Among contemporary U.S. patients undergoing PCI for SIHD, 32.28% clearly met enrollment criteria for the ISCHEMIA trial. There was significant variation among individual centers in the proportion of SIHD patients meeting criteria for the ISCHEMIA trial.
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Affiliation(s)
- Saurav Chatterjee
- Division of Cardiovascular Medicine, North Shore-Long Island Jewish Medical Centers, Northwell Health, Donald and Barbara Zucker School of Medicine New York at Hofstra/Northwell, Hempstead, New York, USA.
| | - Alexander C Fanaroff
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Craig Parzynski
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA; Genesis Research, Pittsburgh, Pennsylvania, USA
| | - Jeptha Curtis
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA; Division of Cardiology, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel M Kolansky
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas M Maddox
- Division of Cardiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Debabrata Mukherjee
- Division of Cardiology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Robert W Yeh
- Smith Center for Outcomes Research, Boston, Massachusetts, USA; Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jay Giri
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Thomas M, Jones PG, Arnold SV, Spertus JA. Interpretation of the Seattle Angina Questionnaire as an Outcome Measure in Clinical Trials and Clinical Care: A Review. JAMA Cardiol 2021; 6:593-599. [PMID: 33566062 DOI: 10.1001/jamacardio.2020.7478] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Patient-reported outcomes are increasingly used as end points in clinical trials, assessments in clinical care, and tools for population health, with an increasing role in quality assessment. For patients with coronary artery disease, the Seattle Angina Questionnaire (SAQ) has emerged as the most commonly used measure of disease-specific health status to quantify patients' symptoms of angina and the extent to which their angina affects their functioning and quality of life. This review explains how to interpret the SAQ and describes the construction and face validity of the SAQ, focusing on aligning scores and changes in scores with clinical constructs. Observations The SAQ asks questions similar to those an experienced clinician would ask of a patient with stable ischemic heart disease. Therefore, SAQ scores can be aligned with clinical constructs (eg, scores on the SAQ angina frequency scale of 0-30 points indicate daily angina, 31-60 points indicate weekly angina, 61-99 points indicate monthly angina, and 100 points indicate no angina), and changes in scores can be described by aligning them with changes in question responses. After clinical thresholds are defined, it is important for clinical trials to not simply report mean differences between treatment arms but to also report the distributions of patients who have had clinically important benefits so that a number needed to treat can be generated. Conclusions and Relevance The widespread use of the SAQ is a consequence of its well-established validity, reproducibility, prognostic importance, and sensitivity to clinical change. Nevertheless, interpreting the SAQ can be challenging because of lack of familiarity with the clinical importance of its domains, either cross-sectionally or longitudinally. This review provides an overview of the interpretability of the SAQ as a foundation for its use as an end point in clinical trials, a tool to support more patient-centered care, and a means of facilitating population health strategies to provide a better foundation for the integration of patient experiences with clinical care.
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Affiliation(s)
- Merrill Thomas
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City
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Miñana G, Núñez J, Marcos-Garcés V, Gavara J, Rios-Navarro C, Bodí V. Long-term prognostic implications of revascularization in patients with known or suspected chronic coronary syndromes without ischemia in vasodilator stress cardiovascular magnetic resonance. Int J Cardiol 2021; 335:15-18. [PMID: 33895211 DOI: 10.1016/j.ijcard.2021.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/13/2021] [Accepted: 04/19/2021] [Indexed: 11/20/2022]
Abstract
AIMS In this study, we evaluated the association between symptoms-guided revascularization occurred within three months following a negative vasodilator stress cardiovascular magnetic resonance (negative stress-CMR) and long-term adverse events in patients with known or suspected chronic coronary syndrome (CCS). METHODS We retrospectively evaluated 3517 patients in which the stress first-pass perfusion imaging revealed no ischemia. The primary endpoint was the composite of death, spontaneous myocardial infarction, heart failure (HF), or stroke. The association between symptoms-guided revascularization after a negative stress-CMR and the endpoint was assessed using the multivariable Cox proportional hazard regression model. RESULTS The mean age was 64.7 ± 11.9 years and 45.4% were females. Coronary angiography and revascularization following a negative stress-CMR were performed in 176 (5%) and 59 (1.7%) patients. At a median follow-up of 4.8 years (2.0-8.2), 529 (15%) patients experienced the primary endpoint (2.0 per 100 person-years). Revascularization following a negative CMR was associated with a higher incidence of the composite (4.85 vs. 1.96 per 100 person-years, p < 0.001) and each of the isolated components of the endpoint, except for the HF endpoint, in which differences were borderline significant. After multivariate adjustment, revascularization remained associated with an excess of risk (HR = 2.01, 95% CI:1.21-3.30; p = 0.007). CONCLUSIONS In CCS patients with persistent symptoms but without evidence of ischemia in vasodilator stress CMR, revascularization was associated with a higher risk of adverse clinical events.
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Affiliation(s)
- Gema Miñana
- Cardiology Department, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Madrid, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Madrid, Spain.
| | - Victor Marcos-Garcés
- Cardiology Department, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Jose Gavara
- Cardiology Department, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Cesar Rios-Navarro
- Cardiology Department, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Vicent Bodí
- Cardiology Department, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Madrid, Spain.
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Abstract
The ISCHEMIA was eagerly awaited study in the field of ischemic heart disease. Following the presentation and publication of ISCHEMIA, multiple opinions and viewpoints get complicated. The ongoing debates have been including the relevance of coronary revascularization, non-invasive diagnostic methods, and invasive ischemic testing in patients with stable ischemic heart disease (SIHD). Prior to ISCHEMIA, observational studies indicated the potential of coronary revascularization for improving clinical outcomes, while the randomized COURAGE trial did not support the plausible concept. Although the FAME 2 trial implied the superiority of percutaneous coronary intervention over medical therapy alone, the clinical relevance of coronary revascularization to improve outcomes and quality of life has been questioned. As a consequence, the ISCHEMIA trial did not demonstrate clear benefits in reducing clinical events but showed antianginal effects of revascularization. This landmark trial also suggested the difficulties of non-invasive ischemia testing rather than computed tomography angiography. Despite the complex results, the ISCHEMIA trial may simplify the clinical indications of coronary revascularization in patients with SIHD. Future publications from the ISCHEMIA trial and debates on the results will sharpen our thinking and understanding.
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