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.