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Cardiac Tests & Treatments to Avoid

Cardiac Tests & Treatments to Avoid

In collaboration with the American Board of Internal Medicine’s Choosing Wisely campaign, the Society for Cardiovascular Angiography and Interventions (SCAI) has issued a list of five specific, evidence-based recommendations that should be avoided in the care of patients who have cardiovascular disease (CVD) or are at risk for it. “This list should be used to spur conversations between patients and physicians so that wise decisions are made about care based on each patient’s individual situation,” says James C. Blankenship, MD. “It’s hoped that this list will improve care for patients and eliminate unnecessary tests and procedures.” Five Recommendations for Patients with CVD The list of tests and treatments to avoid from SCAI includes the following five recommendations: 1. Avoid routine stress testing after PCI without specific clinical indications. 2. Avoid coronary angiography in post-bypass surgery and post-PCI patients who are asymptomatic or who have normal or mildly abnormal stress tests and stable symptoms that do not limit quality of life. 3. Avoid coronary angiography for risk assessment in patients with stable ischemic CVD who are unwilling to undergo revascularization or who are not candidates for revascularization based on comorbidities or individual preferences. 4. Avoid coronary angiography to assess risk in asymptomatic patients with no evidence of ischemia or other abnormalities on adequate non-invasive testing. 5. Avoid PCI in asymptomatic patients with stable ischemic CVD without the demon­stration of ischemia on adequate stress testing or with abnormal fractional flow reserve testing. The list was based on guidelines and appropriate use criteria developed by SCAI, the American College of Cardiology, the American Heart Asso­ciation, and other professional societies. All of the...
Redefining MI After Revascularization

Redefining MI After Revascularization

Numerous definitions for diagnosing myocardial infarction (MI) after coronary revasculariza­tion are currently being used by clinicians. In 2013, the Society for Cardiovascular Angiography and Interven­tions (SCAI) convened an expert panel that proposed new, more meaningful cri­teria for diagnosing MI after PCI or CABG. “Having a standardized MI definition can help clinicians better identify patients with true complications after PCI or CABG who require urgent action,” says Issam D. Moussa, MD, FSCAI, lead author of the SCAI consensus document. “It would also better reflect the quality of coronary revascularization procedures and assist in the design of research trials aimed at developing effective prevention strategies.” New Criteria The new definition of MI differs from existing definitions in several ways, according to Dr. Moussa. “Both diagnose MI by detecting proteins in the blood that are released when the heart muscle is damaged,” he says. “The universal definition calls for a relatively small increase in cardiac troponin (up to five times the normal level), plus confirmation by an ECG, an imaging test, or symptoms. On the other hand, the new SCAI definition calls for a large increase in CK-MB (up to at least 10 times the normal level) in most cases.” If CK-MB is unavailable, SCAI’s new definition calls for a troponin level that is 70 times the normal level. If an ECG provides strong evidence of an MI, then the new definition allows for blood levels of CK-MB that are five times normal and troponin that is 35 times normal. “When patients are diagnosed with an MI, there are important implications to consider,” Dr. Moussa. “These diagnoses could lead to longer hospitalizations,...
Surgical Readmissions and Quality of Care

Surgical Readmissions and Quality of Care

Throughout the United States, reducing the rates of hospital readmissions has become a top priority, as evidenced by CMS planning to include surgical procedures in the expansion of the penalty program. “The hospital readmissions reduction program is predicated on the notion that decreasing the frequency with which patients return to hospitals can improve care and lower costs,” says Thomas C. Tsai, MD, MPH. “However, using medical readmission rates as a measure of hospital quality has been controversial.” Hospitals vary substantially in their medical readmission rates, but these data generally do not correlate with the measures that are often used to identify high-quality hospitals, such as mortality. This raises the question of whether or not medical readmission rates actually measure hospital quality or if they instead reflect other factors that are unrelated to hospital care. The relationship between readmission rates and surgical care may be different than that of medical readmissions. Most patients undergo non-urgent major surgery when they’re clinically stable. As a result, surgical readmissions are more likely to result from complications of care received during index hospitalizations. “Clinicians have relatively little information on the types of hospitals that perform well or poorly with regard to surgical readmission rates,” says Dr. Tsai, “but we hypothesized that hospitals excelling in surgical care would generally have fewer readmissions.” A Comprehensive Analysis In a study published in the New England Journal of Medicine, Dr. Tsai and colleagues sought to determine the patterns of surgical readmissions among Medicare patients across a set of major procedures in a national sample of hospitals. The study team combined information from Medicare claims, the American Hospital Association...
Interpreting Troponin Tests: Coming to a New Consensus

Interpreting Troponin Tests: Coming to a New Consensus

Since its introduction in the early 1990s, cardiac troponin testing has been predominantly used to diagnose or rule out myocardial infarction (MI) in patients with possible symptoms of MI. However, it has become clear that a positive troponin indicates that cardiac injury has occurred, but it is not specific for the etiology of the injury. “Experience with troponin testing has also showed that higher levels identify patients at greater risk for adverse events, regardless of the clinical setting (eg, MI, heart failure, or non-cardiac etiologies),” explains L. Kristin Newby, MD, MHS, FACC, FAHA. “However, more recent studies have raised questions about cardiac troponin cutoffs that should be used for diagnostic and prognostic interpretations and the particular importance of the clinical context in making those interpretations.” In the Journal of the American College of Cardiology, Dr. Newby and colleagues from seven professional societies, led by the American College of Cardiology, released a consensus statement to help clinicians determine when to order troponin testing and how to interpret results. The document provides a framework for clinicians to interpret results of troponin testing in a useful mechanism-based construct. Key Recommendations on Troponin Testing According to the consensus statement, physicians should adopt the definition of MI that was recently updated in order to fully understand the implications of elevated troponin levels. “The universal definition of MI, which was updated in 2012, is important because it provides a standard framework in which to apply troponin testing for a diagnosis of MI and emphasizes not only troponin levels, but also the importance of clinical symptoms of MI,” Dr. Newby says. In addition, the consensus statement...

Avoiding Readmission After CABG

Researchers from New York suggest that readmissions after CABG may be reduced through careful postoperative surveillance for risk factors and frequent causes of readmission. The study team found that cardiac and pulmonary complications, including pleural effusions, were frequent reasons for readmission. Abnormal discharge serum creatinine was also associated with increased readmission rates. Abstract: Journal of the American College of Surgeons, March...
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