52-year-old male with NIDDM presented on January 13, 2014 with new onset unstable angina and inferolateral T wave changes. A cardiac cath revealed complex 2 vessel coronary artery disease with multiple lesions of right coronary artery & left circumflex and normal LV function; SYNTAX score 23. Patient underwent DES x3 of RCA and did well. Now planned for complex PCI of calcified bifurcation, complex lesions of left circumflex coronary artery.
Moderator: Sameer Mehta, MD
Q&A
Q
You mentioned Appropriateness Utilization Criteria (AUC) for PCI as one of your focus areas for this year's webcast? What are the reasons for selecting such an unusual theme?
A.
In my opinion introduction of Appropriate Use Criteria (AUC) was a great
addition to clearly define the appropriate indication of PCI based on the
published data. Therefore stenosis severity alone is no longer the criteria
for PCI, but whether opening it will benefit the pt, is the hall mark of AUC
classification based on symptoms, level of ischemia and use medications.
Hence all PCI programs can easily be judged on the AUC criteria. We have
instituted a strict protocol to follow AUC at MSH right from scheduling the
pt by the referring doctors, pt’s examination after arrival by cath lab
nurse practitioners and at the time of performance of PCI, and this process
has resulted in our (at MSH) very high AUC appropriate and uncertain
indications for PCI with inappropriate being consistently <3% since 2010.
Q
How is Mount Sinai ranked in the AUC?
A.
As per AUC criteria, inappropriate PCI at MSH was 3.6% in 2010 and now is
<3% as per recent ACC-NCDR data of 3rd Q 2013 with national average of 15-19%
during the same time period. That in my opinion should be the lowest in the
nation for large volume (> 2000 PCIs/year) PCI centers. Always there will be
some cases which will fall in the inappropriate category because of clinical
scenario such as pre-op cases (otherwise surgery could be canceled), CAD
presenting as Vtach caused by a significant lesion in a small branch etc.
Q
Is there individual ranking by physician? How are you ranked?
A.
Yes we track AUC ranking by the physicians at MSH and all are in 2-6% range for inappropriate PCI. My rank is in 2-3% range.
Q
Do you sometimes confront referring physicians to whom you have to turn down a procedure as it seems inappropriate?
A.
Yes many times, referring cardiologists get upset for not doing PCI
especially if it is >80-90% lesion. This used to happen often in 2010 but now
over the years by education, all seems to understand the logic and decision
making to defer PCI if recommended.
Q
Has it happened the same way with families too who need a procedure to be turned down?
A.
Yes actually, it is more difficult to convince the family that blockage
left without PCI will not harm the pt and will not cause any death or heart
attack. This process really requires extra steps in explaining and assuring
them.
Q
Do you have assigned staff in your cath lab that specifically reviews AUC?
A.
Yes we assigned this task to one of our cath lab nurse practitioner who
gives us the report monthly as a whole and as per interventionalists.
Q
Has AUC become an important part of the training for your fellows?
A.
Absolutely yes. AUC assignment of a PCI case before PCI is contemplated
has become an integral part of the interventional fellow’s training. Many
times, they are the first one to point out that a particular PCI case is
inappropriate.
Q
In what percentage of cases are you doing platelet testing at your institution?
A.
Now we use platelet inhibition testing by Accumetrics in about 4-5% of PCI
cases; cases of possible stent thrombosis and high risk pt where we cannot
use Prasugrel or Ticagrelor for some reason.
Q
Do you think that routine platelet testing will happen in the future or that this topic has been adequately demonstrated to have limited utility?
A.
In my opinion, routine platelet testing now and in future will not be of
clinical value; this statement is supported by 3 major randomized trial
involving over 4000 pts aggregately in last 4 years. Certainly is some
special cases, it may be indicated.
Q
Is there one subset of patients where you feel obligated to do platelet testing?
A.
Yes pts who had complex PCI (ULM, multi-vessel PCI using >3 stents,
bifurcation PCI with 2 stents, single vessel supplying the heart) and we
can’t use more effective agents (Prasugrel or Ticagrelor), should
preferably get PRU measured before discharge. If PRU is >230, then either use
Clopidogrel 150mg daily or still use newer agents despite their relative
contraindications. (Prasugrel 5mg daily is my favorite in these high PRU
cases even if pt had prior CVA).
