Inappropriate Cath, Appropriate Revascularization

Seth Bilazarian, MD


July 13, 2015

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Hi. This is Seth Bilazarian on on Medscape, for Practitioner's Corner. This is my blog at the end of a STEMI (ST-segment elevation myocardial infarction) weekend, and I spent a fair amount of time thinking about appropriate use during the weekend. Part of it may be that we're just beginning our reaccreditation for ACE (Accreditation for Cardiovascular Excellence) certification for our cath lab, so inappropriate and appropriate use regarding certain criteria have been on my mind a fair amount.

Imperfect Appropriate Use Criteria

There has been a lot of well-voiced criticism that many of the parts of the appropriate use criteria are not perfect in terms of helping us evaluate whether a patient is appropriate for both diagnostic angiography and intervention. The stress testing, the classes of angina—they all have certain deficiencies. But one area that came up, that I realize is not something that happens commonly but is not rare either, is the circumstance whereby a patient has a cath that may be inappropriate—or uncertain, but most likely inappropriate—that ends up being appropriate because the findings show really significant revascularization needs. I thought that this should be called ICAR or UCAR: inappropriate or uncertain cath (IC or UC), appropriate revascularization (AR).

In general, people know that appropriate use is something that is here to stay. It came out in 2009 and was developed by the American College of Cardiology in partnership with multiple professional organizations. It was led by Manesh Patel, who I've had the good fortune to interview on several occasions. It is becoming the national standard to quantify appropriateness of percutaneous coronary intervention (PCI). There was a concern that this might be used by payers. We were assured that it wouldn't be used by payers, but of course New York State tried to use it to deny payments retrospectively for cases that were not deemed appropriate.

There is a lot of concern, legitimate concern, about not only the financial aspects of this—we obviously need reimbursement to continue our mission—but also for patient care issues. Appropriate use is clearly here to stay. Individual interventionalists like me, but also organizations, cath labs, and hospitals, are struggling with compliance.

There is this looming hazard in regard to accreditation and reimbursement, and "rarely appropriate" and "maybe appropriate" under certain circumstances. The appropriate use criteria writers certainly say that we need to be more careful in our documentation, more thorough when we document cases that are rarely appropriate. That really needs to become the default position. More people are doing this, but the appropriate use criteria also may need to evolve more quickly.

We see this as data clarify many of the unknowns, as with a recent example of nonculprit intervention in primary PCI. We all know that the clinical scenarios for appropriate use are guided by the class: acute coronary syndrome (ACS) or non-ACS, the severity of the angina, the extent of the ischemia, low ejection fraction, or other prognostic factors, but a big part of it is the extent of antianginal therapy and the extent of the anatomic disease. Dr Patel and his co-writers have come up with a scheme: You can either use one of those tables that came out in the 2009 JACC paper[1] or the Society for Cardiovascular Angiography and Interventions Quality Improvement Toolkit (SCAI QIT), which is now available as an app for phones. It's also readily available for desktop use for printing the appropriate use criteria. I think it's been very useful.

But in terms of the criteria evolving, my concern is that there are a number of cases that are in this unknown category. The "uncertainty" or "uncertain" category makes up a substantial number of cases—as many as 38%, as reported in the Wall Street Journal[2] in 2011. This "uncertain" category holds two really important categories. It is said that revascularization for PCI in these patients may be a reasonable approach but more research and/or more patient information is needed. Now, those are two distinct things. If it's because the scenario has not been well identified, that's an "uncertain" for a different reason than that the physician either didn't do adequate testing or adequate documentation. I think those two should be distinguished. Whether that's an "uncertain A" and an "uncertain B," it should really be very different, because for those of us who are trying to comply with the appropriate use criteria, having that distinguishing aspect would be very important. I will briefly show two cases that I think are examples of this.

A 54-Year-Old Runner With Angina

Figure 1.

This is a case of a patient who is 54, who runs regularly and runs many miles a week, and who had some angina symptoms while running. He came to my office to discuss the issues. There seemed to be increasing episodes of these angina symptoms, but I couldn't really categorize them more than class I. They never occurred with other kinds of regular activity—only when he was running.

I put the patient on the treadmill and he went for 16 minutes with no angina and no ST-segment abnormalities. That's the highest Duke Treadmill score, 16 points, and very low risk, so really an inappropriate cath. We had a long discussion and shared decision-making. The patient is a very bright, articulate gentleman who wanted to have clarification, because he was quite certain that in his own body there was something very important going on.

In this case, clearly there was a very tight 99% proximal lesion in the left anterior descending artery which I went on to treat with coronary intervention. This is an "inappropriate" cath and an "uncertain" PCI. It's an example of one of these cases where we really are stuck because of the circumstances. If we had new criteria where we could say, "Yes the cath was inappropriate but clearly we found something important," I think it would be clearer. That's one case. Certainly I could have done radionuclide imaging and maybe identified an area of significance that may have changed the inappropriate or appropriate criteria. I could have put the patient on antianginal therapies, but I felt that this patient didn't need that and would be well served to just go ahead with cath after our lengthy discussion.

ST-Segment Elevation on Holter Monitor

Figure 2.

This second case represents that no scenario is clearly defined. This is a patient who had ST-segment elevation on the Holter monitor—really remarkable ST-segment elevation. In the diary, the patient described being "light-headed and uncomfortable." The ST segments went up 6 or 7 mm in 1 week, 5 mm in another, and 4 mm in another on the three-lead Holter monitor. This patient ended up going on for an "inappropriate" cath because there's really no scenario defined for this, for an ulcerated lesion in the proximal right and then more severe disease in the distal right. This patient was managed with medical therapy, but clearly this was a valuable finding and this patient would be appropriate for revascularization, in my view, based on the ST-segment elevation.

In summary, I think that the appropriate use criteria is a very good effort and I think SCAI is trying to be helpful to its members who are practicing physicians. The appropriate use criteria are flawed but it is really necessary in this current environment. I would encourage the AUC committee to continue to iterate this and help us, and maybe including an uncertain A and B notion would be valuable to help us distinguish lack of data vs lack of patient information gathering.

Obviously, individuals and labs are going to need to continue to monitor the adherence with the appropriate use criteria. My hope is that as we move more toward a desire to have shared decision-making, that it's acknowledged that diagnostic testing can improve patient outcomes in many cases.

We often hear about the inappropriate procedure that led to multiple subsequent procedures that caused harm to the patient. Certainly that does happen. But I've never heard anyone say that an inappropriate procedure (like the two I described here) actually led to very appropriate care. Not acknowledging that sometimes these procedures are very valuable is not useful for patients and can cause patients to be underevaluated or undertreated.

So until next time, I'm hoping that you like the idea of an ICAR—an inappropriate cath, appropriate revascularization—as a new distinguishing feature for patients who are undergoing cath and PCI. Thanks.


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