Complex coronary cases
Complex PCI of Calcified Bifurcation, Complex Lesions of LCx – Jan 2014

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

1:26:19

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).


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