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- James C. Blankenship, MD⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. James C. Blankenship, Department of Cardiology 27-75, 100 North Academy Drive, Danville, Pennsylvania 17822
Two thousand years ago, the writer of James neatly summarized 2 of the knottiest problems in interventional cardiology: “To him who knows to do good and does not do it, to him it is [wrong]” (James 4:17). These 2 problems are: 1) identifying the “right thing to do”; and 2) getting it done. In this issue of JACC: Cardiovascular Interventions, Marso et al. (1) try to take us closer to “finding the right thing to do.”
In the past 2 years, 2 documents from the American Heart Association, American College of Cardiology Foundation, and the Society for Cardiovascular Angiography and Interventions have attempted to identify the “right thing to do” (2). The 2009 Appropriate Use Criteria (AUC) (3) and the 2011 Percutaneous Coronary Intervention (PCI) Guidelines (4) used evidence and expert opinion to guide use of PCI in a wide variety of scenarios.
The authors of these documents recognized them to be imperfect, not fully evidence-based, and rapidly outdated by new developments. These criticisms are being addressed. For example, the percentage of recommendations based on published evidence (Level of Evidence: A or B) increased from 51% in the 2005 PCI guidelines (5) to 66% in the 2011 PCI guidelines. An updated version of the 2009 PCI AUC is expected in early 2012, and plans are already underway to update the 2011 PCI guidelines.
Constructive criticism helps physicians put guidelines and AUC in perspective and improve their next iterations. As such, the critique by Marso et al. (1) of the AUC is helpful. Some of their most compelling criticisms are:
1. The 17-person technical panel that developed appropriateness scores included only 4 interventional cardiologists, so that collectively, the group may have failed to recognize some benefits of PCI.
2. 85 cardiologists evaluating the AUC rankings disagreed substantially with the AUC technical panel scores, casting further doubt on the validity of some AUC ratings as “appropriate,” “uncertain,” and “inappropriate” (6).
3. Criteria for rating stress test results as “high,” “intermediate,” or “low” risk were vague, and assignment to these categories may have been unreliable.
4. The AUC rates PCI for class II angina with low-risk stress test results and less than maximal antianginal therapy as “inappropriate,” ignoring the fact that for many patients, class II angina severely limits quality of life (7,8).
5. National Cardiovascular Data Registry ratings of appropriateness provided to hospitals every quarter are based on data that are self-reported, unaudited, and potentially biased.
In a larger sense, the AUC and PCI guidelines attempt to codify and clarify what is “the right thing to do.” They represent the best efforts of intelligent, well-meaning professionals to identify what we know, but as with all such efforts, these are doomed to imperfection. There will always be inadequate evidence, disagreement among experts, and new research rendering current knowledge obsolete.
The next iterations of the guidelines and AUC will be improved but will never fully define the best treatment decision for a particular patient. This is because: 1) occasionally, patients will have exceptional circumstances that dictate treatment different from that recommended by AUC and guidelines; and 2) different patients experience a given level of symptoms differently. In 1 study, 33% of patients were “more bothered” by class II angina than the average patient with class III/IV angina, and patients that are “more bothered” by their symptoms will take greater risks to relieve them than patients “less bothered” (8). Determinations of appropriateness by the AUC based on angina class fail to take patients' perceptions and preferences into account. This is a fundamental flaw, because patients' perceptions and preferences are a critical component of decision making (7,9).
Factoring in patient preferences raises a host of new problems. Patients' preferences are routinely based on incorrect perceptions and nonobjective factors (Table 1 [10–18]). Patients routinely overestimate the benefits of PCI, underestimate its risks, and underestimate the efficacy of medical therapy (10–14,17,18). Patients tend to discount the sometimes superior benefits of 1 treatment (e.g., CABG for very complex triple vessel disease) because those benefits accrue later, and instead prefer the more immediate but lesser benefits of another treatment (e.g., PCI) because they accrue sooner (temporal discounting) (15). Patients' preference for convenience often leads to the same result: PCI provides faster relief than optimal medical therapy, especially when done at the same session as diagnostic catheterization. Physicians need to minimize these biases by providing accurate information and encouraging rational decision making, which may require delaying PCI (19), employing the “heart team approach” (4), or perhaps employing innovative methods of providing informed consent (20).
The final aspect of “doing the right thing” resides with physicians. Physicians are at risk for making nonevidence-based treatment decisions favoring PCI due to lack of awareness of recent research, guidelines, or AUC, malpractice concerns, and the “chagrin factor,” which reflects their fear of adverse consequences resulting from treatment decisions (10,18). Physicians should keep up to date with recent data, be aware of standards such as the AUC and PCI guidelines, seek to understand patients' preferences, and help them make rational decisions.
In summary, the physician and patient seeking to do “the right thing” face many pitfalls. The patient is responsible for carefully considering information provided by caregivers, identifying personal preferences, and then acting as a therapeutic partner as treatment is delivered. The physician is responsible for knowing current data and standards regarding treatment options, providing the patient with information that allows for truly informed consent, understanding the patient's preferences, providing patient-specific advice, and then helping the patient obtain appropriate medical care. It is particularly important when different treatment options are likely to produce similar outcomes, that the physician respect patients' autonomy and encourage them to choose a strategy most consistent with their preferences.
The author has reported that he has no relationships relevant to the contents of this paper to disclose.
↵⁎ Editorials published in the JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology.
- American College of Cardiology Foundation
- Douglas P.S.,
- Wolk M.J.,
- Brindis R.,
- Hendel R.C.
- Patel M.R.,
- Dehmer G.J.,
- Hirshfeld J.W.,
- Smith P.K.,
- Spertus J.A.
- Levine G.L.,
- Bates E.R.,
- Blankenship J.C.,
- et al.
- Chan P.S.,
- Brindis R.G.,
- Cohen D.J.,
- et al.
- Kee F.,
- McDonald P.,
- Gaffney B.
- Arnold S.V.,
- Decker C.,
- Ahmad H.,
- et al.