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 tests and procedures listed have been deemed “inappropriate” or “rarely appropriate” according to the latest appropriate use criteria or are “not recommended” based on the most current professional guidelines. These items were carefully vetted, adjudicated, and agreed upon by experts in the field.
Reducing Waste & Overuse with Cardiovascular Procedures
The Choosing Wisely list from SCAI is important because many procedures are commonly performed in invasive and interventional cardiology, but some are not always necessary. “The content within this list can help physicians and patients throughout the United States engage in conversations about the care that is needed, and what can be done to reduce waste and overuse in the healthcare system,” Dr. Blankenship says.
Discussions between physicians, patients, and their caregivers are critical to delivering optimal, effective care. Dr. Blankenship adds that clinical judgment is also important in determining the best course of care for individual patients. “These recommendations should be viewed as complementary to current guidelines and appropriate use criteria,” he says, “They can enhance our care for patients based on their unique circumstances.”
Readings & Resources (click to view)
Society for Cardiovascular Angiography and Interventions: five things physicians and patients should question. Available at: http://www.scai.org/Assets/08ed25e0-f252-4106-8165-ad4247ef2888/635318539384200000/2014-03-31-scai-5-things-pdf.
Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44-e122.
Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;63:380-406.
Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2012;59:857-881.