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Interventional cardiology

How should the appropriateness of PCI be judged?

Nature Reviews Cardiology volume 8, pages 544–546 (2011)Cite this article

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Every day more than 2,000 patients in the US undergo percutaneous coronary intervention (PCI), usually with the permanent implantation of one or more coronary stents. Few would argue that PCI is life-saving in patients with acute or imminent coronary occlusion, and substantially improves quality of life in patients with severe angina. Conversely, although procedural complications, stent thrombosis, and late restenosis have become relatively uncommon with the latest generation of devices,1 the occurrence of these adverse effects can have serious consequences, and interventional cardiology procedures contribute substantially to the health-care budget. Thus, responsible physicians carefully weigh the likelihood that patients will benefit from such procedures. How are these decisions made? Approximately 30 years ago, physicians largely relied upon experience, intuition, and anecdotes to guide patient care. Since that time, we have entered an era of 'evidence-based medicine', characterized by reliance on randomized trials and observational studies to guide clinical decision-making. Professional societies expend great effort to synthesize thousands of studies into exhaustive clinical guidelines. However, many clinical scenarios are not directly addressed by the guidelines. From this void, 'appropriateness use criteria' (AUC) have emerged, in which diagnostic and therapeutic procedures for a range of typical patient presentations are categorized on an ordinal scale as 'appropriate', 'uncertain', or 'inappropriate'.2 In 2009, a 17-member, expert panel of multispecialty physicians and researchers plus one health-insurance officer chose 198 distinct clinical indications (from more than 4,000 possibilities) and adjudicated the appropriateness of coronary revascularization on the basis of combinations of clinical symptom acuity, symptom severity, extent of ischemia, select high-risk clinical features, number of antianginal medications, and the extent of anatomical coronary artery disease.2

...the vast majority of PCIs performed in patients with ACS ... were considered appropriate...

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Acknowledgements

We gratefully acknowledge the insights on this topic provided by Paul S. Teirstein, Scripps Clinic and Research Foundation, La Jolla, CA, USA.

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  1. NewYork-Presbyterian Hospital, Columbia University Medical Center and the Cardiovascular Research Foundation, 111 East 59th Street, 11th Floor, New York, 10022, NY, USA

    Gregg W. Stone & Jeffrey W. Moses

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  1. Gregg W. Stone
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Correspondence to Gregg W. Stone.

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Competing interests

G. W. Stone is a consultant for Abbott Vascular, Boston Scientific, and Medtronic. J. W. Moses is a consultant for Boston Scientific and Cordis.

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Stone, G., Moses, J. How should the appropriateness of PCI be judged?. Nat Rev Cardiol 8, 544–546 (2011). https://doi.org/10.1038/nrcardio.2011.135

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