Angiography provides gateway for some inappropriate PCIs

Hospitals that want to reduce inappropriate PCI rates may want to look beyond the cath lab for opportunities. A study published online Aug. 25 in JAMA Internal Medicine identified diagnostic coronary angiography in asymptomatic patients as a red flag for PCI overuse.

Efforts to reduce rates of inappropriateness of PCIs have put the spotlight on interventional cardiologists. Steven M. Bradley, MD, MPH, of the Veterans Affairs Eastern Colorado Health Care System in Denver, and colleagues proposed that providers who select patients for diagnostic coronary angiography may play a role.

“Given the potential for diagnostic-therapeutic cascade, in which an initial diagnostic test triggers subsequent treatments regardless of clinical benefit, it is possible that greater use of angiography in asymptomatic patients leads to more frequent appropriate use criteria-defined inappropriate PCI,” they speculated. On the other hand, patient selection for angiography and PCI may be unrelated.

To test the association between angiography in asymptomatic patients and PCI appropriate use rates, they analyzed data from the CathPCI Registry. Their study included 544 hospitals that performed more than 1 million elective coronary angiograms and more than 200,000 elective PCIs between 2009 and 2013.

The researchers found that 25.1 percent of patients were asymptomatic at the time of their angiography. The hospital proportion of angiographies on asymptomatic patients ranged from 1 percent to 73.6 percent. Hospitals with higher rates of asymptomatic patients at angiography also had higher rates of inappropriate PCIs and lower rates of appropriate PCIs.

Bradley and colleagues attributed the higher rate of inappropriateness to more frequent use of inappropriate PCIs in asymptomatic patients. Hospitals in the lowest quartile, for instance, had a rate of 5.4 percent vs. 21.6 percent for hospitals in the highest quartile.

“[O]ur findings suggest an opportunity to address patient selection before proceeding to the catheterization laboratory to optimize the use of angiography and PCI,” they wrote.

They placed responsibility for proper patient selection not only on interventional cardiologists but also referring physicians. Considering the volume and cost—more than 1 million coronary angiographies annually at $9,000 a procedure—they emphasized the need for better strategies to improve patient selection for coronary angiography.