• The PCI bias

    From Mark Hlatky in NEJM, commenting on a the latest trial comparing the effectiveness of percutaneous coronary intervention (PCI, or angioplasty/stenting) with coronary artery bypass grafting (CABG) for diabetes patients with multivessel disease:

    Despite the results of BARI and other trials, over time more and more patients with diabetes have undergone PCI rather than CABG to treat multivessel coronary disease. The reasons for this trend are uncertain, yet there are two broad potential explanations. First, because PCI technology continues to evolve, many cardiologists simply have dismissed the results of earlier randomized studies as outdated because they used earlier techniques. This is a catch-22, since long-term studies are needed to compare hard outcomes, but evidence from long-term studies may be ignored if therapies are evolving. The results of the FREEDOM trial suggest that the comparative effectiveness of CABG and PCI on hard outcomes remains similar whether PCI is performed without stents, with bare-metal stents, or with drug-eluting stents. Mortality has been consistently reduced by CABG, as compared with PCI, in more than 4000 patients with diabetes who have been evaluated in 13 clinical trials. The controversy should finally be settled.

    Another potential reason for the increasing use of PCI in patients with multivessel coronary disease is that the clinical-decision pathway leads patients toward PCI over alternative treatments. Many PCIs today are ad hoc procedures, performed at the time of diagnostic coronary angiography, with the same physician making the diagnosis, recommending the treatment, and performing the procedure. There is little time for informed discussion about alternative treatment options, either medical therapy on the one hand or CABG on the other. Well-informed patients might choose any of those options on the basis of their concerns about the various outcomes of treatment, such as survival, stroke, myocardial infarction, angina, and recovery time. This is a complicated decision, and clinical guidelines in the United States and Europe now emphasize the importance of more deliberate decision making about coronary revascularization, including discussions with a multidisciplinary heart team.

    I’ll have a lot more to say about PCI and CABG later this month. For now, notice the bias toward PCI that Hlatky describes.

    @afrakt

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    • “Many PCIs today are ad hoc procedures, performed at the time of diagnostic coronary angiography, with the same physician making the diagnosis, recommending the treatment, and performing the procedure. ”

      I think this is the crux of the matter. A cardiologist can make a quick few thousand dollars more for a few extra minutes work during the procedure. This is a powerful incentive to avoid critical thinking about what’s best for the patient.

      I have had friends and relatives who have been on the receiving end of this “decision making”. They have some minor problem, get a cath and come out with a stent (or two). No discussion.

    • From October, 2012.
      • Patients who were deemed appropriate and did not get revascularization had a 39 per cent increase risk of adverse outcomes compared with those who received treatment.

      • Sixty-eight per cent (68%) of all coronary revascularizations (angioplasty or bypass surgery) were considered appropriate. These patients clearly benefitted from the procedures

      • Eighteen per cent (18 %) of all coronary revascularizations were considered uncertain on grounds of appropriateness.

      • Fourteen per cent (14%) of all coronary revascularizations were considered inappropriate.

      • Patients who were uncertain or inappropriate and received revascularization did not get any benefits from the procedures.

      http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=117&morg_id=0&gsec_id=3086&item_id=7724&utility_link_id=3086