The Society for Cardiovascular Angiography and Interventions (SCAI) issued a consensus statement Nov. 29 updating recommendations about appropriate use of ad hoc PCI, or PCI performed at the same time as a diagnostic coronary angiography. The update was published online Nov. 29 in Catheterization and Cardiovascular Interventions.
The authors, James C. Blankenship, MD, of Geisinger Medical Center in Danville, Pa., and colleagues, noted with concern that in recent years ad hoc PCI is performed in situations in which it may be preferable to wait before going forward with the procedure. The statement emphasized that except in emergent situations, PCI should be an option that is selected with full patient participation, as part of a comprehensive treatment plan.
The comprehensive treatment plan should include patient consent prior to sedation that includes thorough discussion of all treatment options and their risks and benefits, adequate testing to ensure that PCI is an appropriate option in the patient’s particular circumstance, a risk assessment of both long- and short-term treatment options, and appropriate scheduling to allow for ad hoc PCI, should it be necessary. Depending on the severity of the patient’s blockages, consultation with a heart surgeon may be appropriate before deciding on a care plan.
The statement refers to the 2012 Appropriate Use Criteria (AUC) 3 for PCI, and extends the principles in that document to establish recommendations regarding the timing of the PCI procedure. The AUC establish appropriateness based on clinical presentation, extent and degree of ischemia revealed by noninvasive testing, adequacy of medical therapy and extent of anatomic coronary artery disease (CAD). “The AUC suggest that, for patients without severe symptoms, prior functional testing confirming ischemia, and/or an attempt to provide optimal medical therapy, PCI is generally inappropriate,” the authors of the guidelines wrote. Thus, the guidelines urge clinicians not to perform ad hoc PCI in such patients, but to wait until there are sufficient indications that the intervention is necessary.
The guidelines advocated for ad hoc PCI when tests reveal the patient is having a heart attack or an MI is imminent. They support ad hoc PCI in patients with stable heart disease if optimal medical treatment has been ineffective and severe damage to the heart muscle is possible, and a risk benefit analysis indicates that patients will likely find relief of severe symptoms. The guidelines suggest that ad hoc PCI is usually not appropriate in patients with very complex CAD, unless surgery is contraindicated and the patient is aware of the risks and benefits.
The authors conceded that ad hoc PCI is more convenient for the patient and more cost-effective, and that patients often prefer to have blockages cleared as soon as they are discovered. However, “When the patient’s blockages appear to be stable, it may be advisable to stop the procedure and discuss the test results with patients and family members,” Blankenship said in a release. “The new recommendations will help physicians ensure they are taking the right steps to provide the best care for each patient.”