Ad hoc coronary intervention

Ad Hoc percutaneous coronary interventions in patients with stable coronary artery disease—A study of prevalence, safety, and variation in use from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR®)

OBJECTIVE

To utilize the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) to monitor the performance and safety of ad hoc PCIs.

BACKGROUND

The performance of ad hoc PCI remains controversial. Patients' preference, cost, and vascular access issues favor an ad hoc strategy. Adequate time for thoughtful decision-making, scheduling complexity, informed consent, and physician reimbursement favor PCI on a subsequent day.

METHODS

We analyzed results in 68,528 patients with stable angina entered in the ACC-NCDR from 2001-2003. Ad hoc PCI was evaluated in many clinical and nonclinical subgroups. A multivariable analysis was performed to determine whether ad hoc PCI had an independent relationship with complications or procedure success.

RESULTS

Overall, 60.6% of patients underwent ad hoc PCI. There was no difference in ad hoc PCI mortality, renal failure, or vascular complications from staged PCI. A lower percentage of patients at high vs. low risk and with vs. without renal failure underwent ad hoc PCIs (58.6% vs.63.0% and 50.7% vs. 60.9% respectively). There was wide variation in the performance of ad hoc PCIs according to payer (70.2-60.3%), hospital PCI volume (67-50.2%), hospital owner (89.7-59.6%), and geographic area (75.5-47.4%). Ad hoc PCI per se was not independently related to PCI success or complications.

CONCLUSIONS

PCI success was related to patient/lesion related factors and not to the performance of ad hoc PCIs per se. Although ad hoc PCI can be performed in more patients than at present, this strategy will never be possible in all patients at all times.

Ethics in Interventional Cardiology: Combining Coronary Intervention With Diagnostic Catheterization

As coronary intervention procedures have become more common, their performance at the time of diagnostic coronary arteriography has become more routine. Combined arteriography and coronary intervention may be slightly less costly and, for some patients, more dangerous than staged intervention. Combined intervention is appropriate in selected patients if they are well informed and it can be done safely; however, a combined strategy should not be applied to all patients.

Acute coronary syndromes: extending medical intervention for five days before proceeding to revascularization

Intensive medical therapy before percutaneous coronary intervention appears to improve results in patients with unstable angina and non-ST-segment elevation myocardial infarction (MI). In this review of treatment strategies for patients with acute coronary syndromes, an "aggressive conservative" approach based on that used in the FRagmin and Fast Revascularisation during InStability in Coronary artery disease (FRISC II) trial is recommended. In FRISC II, an early (but not emergent) invasive therapeutic procedure undertaken within 7 days of starting open-label dalteparin lowered the risk of death and MI in moderate- and high-risk patients and resulted in better and more rapid symptom relief and fewer hospital readmissions than the noninvasive approach. The early treatment period represents a critical juncture in the spectrum of care for patients with unstable angina and affords physicians the best opportunity to educate them about the importance of risk factor modification. Informed consent is also an important issue, particularly in the event of ad hoc coronary intervention. The optimal treatment plan must include considerations of length of hospitalization, medication requirements, and the potential for symptom recurrence or need for hospital readmission. Finally, tailoring therapy for individual patients and establishing appropriate timing of procedures will help ensure the best possible outcome.