Are Unnecessary Coronary Procedures Being Performed?

A common medical procedure in the U.S., performed to open narrowed coronary arteries, is called a "percutaneous coronary intervention" or PCI. PCIs are defined as angioplasty with or without the placement of a stent. But are PCIs really needed as often as they are performed? The public and the medical profession have recently asked this question. Let's look at the results just in from a study reviewing this issue.

How often are PCIs inappropriate?

Results published in a recent issue of the Journal of the American Medical Association from an expert panel examined data from more than 500,000 percutaneous interventions (PCIs). The PCIs were carried out between July 2009 and September 2010 at 1,091 U.S. hospitals. Appropriateness of the procedure was based on criteria recently adopted by a team of 17 heart experts.

The good news is that the panel classified as appropriate 99 percent of the procedures done in patients who had suffered an acute heart attack or unstable angina (procedures in such patients account for about 70 percent of all PCIs).

In contrast, only half of those done for nonacute indications were classified as appropriate. For 38 percent of this nonacute group, the appropriateness was considered uncertain, and in 11.6 percent the procedures were designated inappropriate. Almost all of the inappropriate procedures were carried out in patients who either had no symptoms (angina) or only mild symptoms. The rates of inappropriate PCIs varied enormously from one hospital to another. In one quarter of the hospitals the rate of inappropriate PCIs was less 6 percent, while some hospitals the inappropriate rate was as high as 40 to 50 percent.

What are the costs of PCIs?

The cost of a PCI is about $20,000. Given this, the approximately 600,000 PCIs performed each year in the U.S. cost roughly $12 billion. A Senate Finance Committee, which investigated a Maryland cardiologist who allegedly performed unnecessary PCIs on many patients, concluded that Medicare paid some $27.5 billion for PCIs in six years through 2009. This means that inappropriate PCIs represent an enormous unnecessary cost to individuals and to the overall health care system.

Why are there so many inappropriate PCIs?

The growing efforts to prevent heart attacks and strokes by identifying risk factors are important and desirable. Nonetheless, an unwanted consequence results when the presence of risk factors in an individual with no symptoms leads a cardiac catheterization that shows some narrowing of the coronary arteries. The person’s doctor then decides to treat the partially blocked arteries with PCI. Presumably, the inappropriate PCI is done with the best interest of the doctor’s patient in mind, but it is hard to ignore the large financial gains that result from PCIs, whether appropriate or not.

Professional societies deserve credit for carrying out this “self-policing" study

The data was obtained from a National Cardiology Data Registry, which funded the study, a joint initiative of the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions. It is encouraging that these professional societies undertook a study to determine the appropriateness of their treatments.   

What should you do if a PCI is recommended when you have stable chronic heart symptoms (angina) or no angina at all?

  • Find out if you are getting ideal treatment for angina and for preventing a heart attack. Studies have shown that PCIs were no better over a five year period than optimal medications to treat angina and risk factors like elevated LDL cholesterol and high blood pressure. It is noteworthy that 96 percent of the patients who underwent an inappropriate PCI had suboptimal treatment for angina and for their risk factors, according to this study.
  • Get a second opinion, if possible from a cardiologist associated with a different hospital.


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