APpropriAteness of percutaneous Coronary interventions in patients with ischaemic HEart disease in Italy: the APACHE pilot study

Abstract

Objectives: To first explore in Italy appropriateness of indication, adherence to guideline recommendations and mode of selection for coronary revascularisation.

Design: Retrospective, pilot study.

Setting: 22 percutaneous coronary intervention (PCI)-performing hospitals (20 patients per site), 13 (59%) with on-site cardiac surgery.

Participants: 440 patients who received PCI for stable coronary artery disease (CAD) or non-ST elevation acute coronary syndrome were independently selected in a 4:1 ratio with half diabetics.

Primary and secondary outcome measures: Proportion of patients who received appropriate PCI using validated appropriate use scores (ie, AUS≥7). Also, in patients with stable CAD, we examined adherence to the following European Society of Cardiology recommendations: (A) per cent of patients with complex coronary anatomy treated after heart team discussion; (B) per cent of fractional flow reserve-guided PCI for borderline stenoses in patients without documented ischaemia; (C) per cent of patients receiving guideline-directed medical therapy at the time of PCI as well as use of provocative test of ischaemia according to pretest probability (PTP) of CAD.

Results: Of the 401 mappable PCIs (91%), 38.7% (95% CI 33.9 to 43.6) were classified as appropriate, 47.6% (95% CI 42.7 to 52.6) as uncertain and 13.7% (95% CI 10.5% to 17.5%) as inappropriate. Median PTP in patients with stable CAD without known coronary anatomy was 69% (78% intermediate PTP, 22% high PTP). Ischaemia testing use was similar (p=0.71) in patients with intermediate (n=140, 63%) and with high PTP (n=40, 66%). In patients with stable CAD (n=352) guideline adherence to the three recommendations explored was: (A) 11%; (B) 25%; (C) 23%. AUS was higher in patients evaluated by the heart team as compared with patients who were not (7 (6.8) vs 5 (4.7); p=0.001).

Conclusions: Use of heart team approaches and adherence to guideline recommendations on coronary revascularisation in a real-world setting is limited. This pilot study documents the feasibility of measuring appropriateness and guideline adherence in clinical practice and identifies substantial opportunities for quality improvement.

Trial registration number: NCT02748603.

Keywords: coronary heart disease; multidisciplinary decision making; percutaneous coronary intervention.

Conflict of interest statement

Competing interests: ICJME forms are available for all authors. SL reports honoraria for advisory boards from AstraZeneca, Daiichi Sankyo, and The Medicines Company during the conduct of the study outside the submitted work; LDL reports personal fees from Astra Zeneca, personal fees from Bayer, personal fees from Boehringer-Ingelheim, personal fees from Eli Lilly and Daiichi Sankyo, personal fees from Menarini, personal fees from The Medicines Company, outside the submitted work. SDS reports personal fees from Pfizer, personal fees from AstraZeneca, personal fees from Daiichi Sankyo, personal fees from Correvio, outside the submitted work. The other authors report nothing to disclose. All authors have read and understood BMJ policy on declaration of interests and have no other relevant interests to declare in addition to these.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Figures

Figure 1

Histogram of appropriate use score according to site-reported coronary anatomy (AUSSITE) in patients with and without diabetes.

Figure 2

Error bars of AUSSITE (left) and AUSCORE (right) by participating sites. The dotted line indicates the median AUSSITE level (5.8). AUS, appropriate use score.

Figure 3

Box plot of AUSCORE in patients who underwent and who did not undergo local heart team discussion, stratified by diabetes status. AUS, appropriate use score.