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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...
Guidelines for Managing Stable Ischemic Heart Disease

Guidelines for Managing Stable Ischemic Heart Disease

Nearly 10 million Americans have stable ischemic heart disease (SIHD), which ranks among the leading causes of death among adults in the United States. According to study data, SIHD was the cause of nearly 380,000 deaths in the U.S. in 2010. The total costs associated with caring for heart disease has been estimated at $316.4 billion, while the total cost for coronary heart disease accounts for about $177.1 billion (Figure 1). More than 5 years have passed since guidelines were released on the management of patients with SIHD. In an effort to revisit those recommendations, the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines and five other medical societies collaborated to release a 2012 guideline update for these patients that was published in Circulation. Influential Studies Shaping Revascularization The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial helped shape the revascularization section of the guidelines update, according to James C. Blankenship, MD, FSCAI, who was on the task force that revised the recommendations. “For the COURAGE trial, stable patients in whom catheterization demonstrated a need for revascularization were randomized to medical therapy or coronary intervention. The researchers concluded that neither showed a benefit with regard to death or heart attack. Stenting showed a benefit in angina control for 3 years. This finding, along with data from other studies, indicates that every lesion doesn’t necessarily need to be fixed and that the strongest indication for coronary stenting in stable patients is relief of symptoms.” Revisions in the revascularization section were also shaped by results of the Synergy Between Percutaneous Coronary Intervention With Taxus...
Improving QOL With Coronary Interventions

Improving QOL With Coronary Interventions

For more than 30 years, research has indicated that PCI decreases mortality in STEMI and reduces recurrent ischemic events in patients with non-ST elevation acute coronary syndrome. The overriding goal in performing PCI for these patients is to reduce morbidity and mortality, but quality of life (QOL) is another important aspect to consider. Studies comparing QOL after PCI versus medical therapy or CABG generally report on angina, but this is only one symptom that is relieved by coronary interventions. PCI can also enhance the ability to function, exercise, and perform activities of daily living in many patients. Some comorbidities, however, can limit QOL before and after PCI and may minimize the chances of any improvement in QOL after undergoing the procedure. Individualizing Approaches for PCI & CABG The Society of Cardiovascular Angiography and Interventions (SCAI) released a consensus statement on the effect of PCI on QOL. Published in an issue of Catheterization and Cardiovascular Interventions, the document recommends that clinicians take into consideration that improvements in QOL due to PCI vary from patient to patient. For example, patients who are severely limited by angina will have dramatic improvements in QOL if PCI relieves the angina. However, patients who are severely limited by other medical problems may not experience much improvement in QOL after PCI. Investigations comparing CABG to PCI suggest that QOL is better in the first few months after PCI. At 3 to 5 months, QOL is similar for both PCI and CABG. After 1, 3, and even 5 years, however, QOL tends to be better for patients who receive CABG. When counseling patients on treatment decisions, SCAI...

Multivessel PCI: Coming to a Consensus

When PCI is used to treat multivessel coronary artery disease (CAD), single-vessel or multivessel interventions can be performed in one or more stages. About half of all patients with CAD have blockages in multiple arteries, and as many as 20% of those undergoing PCI receive treatment in more than one vessel. The choice of strategy may influence safety and efficacy, convenience for patients, and cost and reimbursement. In some cases, careful consideration will lead to a single-vessel PCI, and other lesions will be managed medically. In others, multivessel PCI may be considered in the same procedure or in multiple stages. Every patient who undergoes PCI should receive optimal therapy for coronary disease, ideally before starting the procedure. James C. Blankenship, MD, FSCAI Guidance From SCAI for PCI Splitting PCI into separate sessions is less convenient for patients and more costly to insurers. As a result, cardiologists may feel pressured into doing too much in one session, which can be dangerous for some patients. In the November 9, 2011 issue of Catheterization and Cardiovascular Interventions, the Society for Cardiovascular Angiography and Interventions (SCAI) published a comprehensive consensus document that reviews treatment options for patients with multivessel CAD. Recommendations are also provided for the treatment of multiple vessels in one or multiple stages. The goal of the SCAI document is to offer guidance for treating these patients. It is designed to ensure that every step of PCI is as safe as possible and appropriate for each patient’s individual health condition (see also, Reducing Cardiovascular Events After PCI). The document provides several recommendations for treating multivessel CAD: Medical therapy: Every patient who...
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