Author Interview Bairey Merz CN.
Ranolazine improves angina in women with evidence of myocardial ischemia but no obstructive CAD.

Recent Changes in Practice of Elective Percutaneous Coronary Intervention for Stable Angina

Circ Cardiovasc Qual Outcomes.
doi:10.1161/CIRCOUTCOMES.110.957175

1. Bina Ahmed, MD, Harold L. Dauerman, MD, Winthrop D. Piper, PhD,John F. Robb, MD, Peter Verlee, MD,Thomas J. Ryan Jr, MD,David Goldberg, MD, Richard A. Boss Jr, MD,William J. Phillips, MD, Frank Fedele, MD,David Butzel, MD,David J. Malenka, MD and on behalf of the Northern New England Cardiovascular Disease Study

Background The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial was designed to compare optimal medical therapy alone versus optimal medical therapy and percutaneous coronary intervention (PCI) for treatment of patients with stable coronary artery disease and showed equal efficacy for optimal medical therapy with or without PCI. The impact of results from the COURAGE trial on clinical practice is unknown.

Methods and Results We analyzed 26 388 consecutive patients from the Northern New England Cardiovascular Disease PCI Registry who underwent PCI between January 2006 and June 2009.

We identified a COURAGE-like patient group as patients who were undergoing (1) an elective procedure; (2) for an indication of stable angina; and (3) on the day of admission (ie, the date of admission was the same as the procedure date). All other PCI patients were placed in an “other indications” cohort.

We compared temporal trends in overall volume in PCI for stable angina and for other indications, comparing quarterly time periods before and after release of COURAGE in March 2007. Over the study period, there was a statistically significant decrease in total PCI volume from 2064 in Quarter 1 2006 (before COURAGE) to 1708 in Quarter 3 2007 (after COURAGE) (P<0.01).

These trends were sustained through June 2009, with an approximate 16% peak relative reduction in all PCI compared with before COURAGE. As a percentage of all PCI, stable angina reached a high of 20.9% before COURAGE and began to decrease immediately after publication of COURAGE in Quarter 2 2007 to 16.1% (P<0.01).

Among patients undergoing PCI for stable angina, there was a significant 26% peak decrease in post-COURAGE PCI volumes compared with pre-COURAGE Quarter 1 2006 (P trend, 0.01), which was maintained through the end of the study period.

Conclusions Publication of results from the COURAGE trial was temporally associated with a significant and sustained decline in the use of PCI to treat patients with stable angina. The long-term impact of this change in practice on patient outcomes remains to be determined.

Author Interview: Dr. Bina Ahmed

Use of a Screening Tool Improves Appropriate Referral to an Electrophysiologist for Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death

Circulation: Cardiovascular Quality and Outcomes. 2011; 4: 152-156
Laura M. Gravelin, MD, Jennifer Yuhas, BS, Michael Remetz, MD,  Martha Radford, MD,  John Foley, MD and  Rachel Lampert, MD

Abstract

Background— Despite data showing the benefits of implantable cardioverter-defibrillator (ICD) insertion for primary prevention in populations at risk for sudden death, professional society guidelines recommending primary prevention, and recognition by payers of the clinical value of ICDs in these populations, ICDs for primary prevention remain underused. We sought to determine whether implementing a screening tool would increase appropriate identification of patients showing clinical evidence of ICD benefit and prompt referral to an electrophysiologist for ICD implantation.
 
Methods and Results— Screening tools were affixed to medical records for patients seen in 2 outpatient cardiology offices that queried ejection fraction and whether referral to an electrophysiologist was made (N=6632).

The number of appropriate referrals in the screening period were compared with analogous data collected before implementation of the screening tool (control period) through retrospective record review (n=3606). Significantly more eligible patients were offered referral during the screening period than during the control period at both sites, 80% (8/10 eligible) versus 33% (5/15) at site 1 (P<0.02) and 100% (44/44) versus 60% (21/35) at site 2 (P<0.001). Of all patients offered referral, 41% (32/78) accepted.

Conclusions— The use of a screening tool increases referral to electrophysiology for patients in whom placement of an ICD confers the benefit of sudden cardiac death primary prevention. Barriers to referral include both physician and patient factors. Verification of these findings on a larger scale as well as studies defining the foundation of these barriers may further improve use of ICDs in patients for whom their mortality benefit is well described.

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