PCI centers that don’t provide on-site surgical backup caught a break on March 17 with the publication of a paper that consolidates recommendations into a single document. “We tried to take everything that has been out there and put it all in one resource so people don’t have to hunt around,” lead author Gregory J. Dehmer, MD, told Cardiovascular Business.
Dehmer, director of the cardiology division at Baylor Scott & White Health in Temple, Texas, and colleagues from several cardiovascular societies reviewed the myriad of publications that address PCIs performed without surgical backup. The practice was frowned upon less than a decade ago, but studies such as CPORT-E put many concerns to rest. CPORT-E results showed similar outcomes for patients who received elective PCI at hospitals with and without onsite cardiac surgery.
Victories on a number of fronts have posed a conundrum in PCI that the consensus recommendations address. Reductions in restenosis thanks to drug-eluting stents, better medical management of patients using therapies such as statins, more public awareness of cardiovascular risk factors, heightened sensitivity about potential overuse of stenting and a downward trend in ST-segment elevation myocardial infarctions (STEMIs) have decreased the number of PCIs performed.
Some PCI centers consequently are challenged to meet volumes of 200 or more PCIs, a cutoff that in the past has been associated with poor outcomes. The consensus document outlines facility requirements and provides recommendations that are designed to maintain patient safety at smaller volume centers.
Dehmer predicted that the decrease in PCIs will eventually level off while knowledge about optimal patient care will advance. “There will always be people having acute coronary syndromes, STEMIs and [who] need to have a PCI,” he said. “As a therapy, PCI is not that old; it is a little over 30 years old. We are still continuing to learn daily about who will benefit the most and who can have a procedure deferred.”
The recommendations are an update of a 2007 Society for Cardiovascular Angiography and Interventions expert consensus document. The 2014 recommendations incorporate assessments and expert opinion from members representing the American College of Cardiology Foundation and American Heart Association as well.
The 2014 document lists several new recommendations, including:
- Access to intravascular ultrasound and fractional flow reserve in addition to other interventional equipment;
- Definition of geographic isolation as emergency transport of a STEMI patient to another facility of more than 30 minutes;
- Guidance on newly trained interventional cardiologists with an emphasis on mentoring and oversight.
“None of this should be viewed as earth-shattering,” Dehmer said. “It is just a further maturity of things.”
The 2014 consensus document is available online in Catheterization & Cardiovascular Interventions, Journal of the American College of Cardiology and Circulation: Journal of the American Heart Association.