By Jeffrey Zimmet, MD, PhD
Associate Professor of Medicine, University of California, San Francisco; Director, Cardiac Catheterization Laboratory, San Francisco VA Medical Center
In this retrospective analysis of patients from the New York state percutaneous coronary intervention (PCI) and coronary artery bypass grafting databases, ad hoc PCI was performed frequently among patients with left main and multivessel disease. Also, variability in ad hoc PCI use among hospitals and physicians for these populations was high.
Hannan EL, Zhon Y, Cozzens K, et al. Ad hoc percutaneous coronary intervention in stable patients with multivessel or unprotected left main disease. JACC Cardiovasc Interv 2023;16:1733-1742.
Performing a percutaneous coronary intervention (PCI) concurrently with an initial invasive coronary angiogram, often referred to as ad hoc PCI, offers different advantages and disadvantages for clinically distinct patients. The ST-elevation myocardial infarction (STEMI) patient, or the non-ST-elevation acute coronary syndrome patient with ongoing critical ischemia, will benefit from immediate PCI in most cases. However, in stable patients — specifically, in stable patients with coronary anatomy suggesting a potential benefit to coronary artery bypass graft (CABG) surgery — ad hoc PCI may usurp the role of the heart team in helping make the best possible revascularization decisions.
To evaluate trends in ad hoc PCI use, Hannan et al used data from New York state’s mandatory PCI and CABG registries to identify stable patients undergoing cardiac catheterization with multivessel or left main disease. Patients with STEMI or non-STEMI (NSTEMI) within 24 hours were excluded, as were patients with shock, catheterization lab complications, or any previous revascularization. Patients were included if they had been diagnosed with significant left main (LM) disease, three-vessel disease, or two-vessel disease involving the proximal left anterior descending (LAD) coronary artery.
Between late 2017 and late 2019, the authors included 8,196 patients who met the criteria. In this sample, 6,425 of 8,196 PCI patients with multivessel or LM disease (78.4%) underwent ad hoc PCI. Ad hoc PCI was performed in 58.7% of patients with unprotected LM disease, and in 76.7% of patients with three-vessel disease. Patients managing diabetes were less likely to undergo ad hoc PCI compared to those without diabetes (75.7% vs. 80.4%; P < 0.0001). Similarly, patients with left ventricular ejection fraction (EF) less than 35% were less likely to undergo ad hoc PCI compared to those with higher left ventricular EF (64.6% vs. 80.5%; P < 0.0001). Interestingly, patients in hospitals without on-site cardiac surgery capabilities were more likely to undergo ad hoc PCI compared with patients in hospitals equipped with on-site surgery capacity (86.1% vs. 76.6%; P < 0.0001).
When using all revascularization rather than only PCI as a denominator — a marker of what proportion of patients underwent the heart team approach — ad hoc PCI was performed in 35% of all patients. Ad hoc PCI was performed in 11.5% of patients with unprotected LM disease, 64% of proximal LAD patients, and 32% of three-vessel disease patients. Among hospitals equipped with on-site cardiac surgery capacity, there was considerable variability at both the physician and hospital levels regarding ad hoc PCI use.
Hospitals were subdivided into quartiles based on the percentage of PCIs performed ad hoc. For patients with three-vessel disease, hospitals in the lowest quartile performed ad hoc PCI 50% of the time vs. 94.2% in the highest quartile. Similarly, for LM disease, the procedure rate ranged from 25.6% to 93.7%.
The authors concluded that rates of ad hoc PCI are higher for patients with LM and multivessel disease. Rates were significantly lower among patients with diabetes and reduced EF, and higher at hospitals without on-site cardiac surgery capacity. Considering the variability among hospitals and physicians on this metric, Hannan et al posited systems-level change may be in order to achieve consistent levels of heart team consultation.
COMMENTARY
The intent of this analysis was to focus on subsets of patients for whom decisions about revascularization are more complex, and for whom consideration of CABG vs. PCI likely is in order. The authors did the best they could using administrative data to exclude patients in an unstable clinical situation for whom immediate intervention is warranted.
There are other scenarios in which elective surgical consultation is unlikely to change the decision to go to PCI. This includes elderly patients or those living with comorbidities that would make CABG risk-prohibitive, along with patients without suitable surgical targets for bypass. Some subsets of patients could have gone through surgical consultation before angiography, and some patients make clear they would not consider CABG during the consent process for cardiac catheterization.
Even exempting these situations and the possibility of informal surgical consultation during the catheterization procedure, the main finding here is the rate of ad hoc PCI remains surprisingly high in this contemporary study. This is not to say ad hoc PCI is not appropriate in many or even most of these cases.
However, the magnitude of variability in using ad hoc PCI at both the hospital and physician levels is extremely wide, reflecting differences in local practice regarding coronary artery disease management. For example, the higher use rate of ad hoc PCI at sites without on-site cardiac surgical backup likely reflects the greater effort involved in obtaining timely consultation at these centers.
The use of a heart team approach has been a Class I recommendation for some higher-risk subsets of coronary disease since the publication of the 2012 American College of Cardiology guidelines for management of stable ischemic heart disease.1 More work remains to create systems that lower the barriers to heart team consultation and that make it most likely patients are offered the best revascularization options based on their preferences.
REFERENCE
1. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014;64:1929-1949.
