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

ObjectivesTo first explore in Italy appropriateness of indication, adherence to guideline recommendations and mode of selection for coronary revascularisation.DesignRetrospective, pilot study.Setting22 percutaneous coronary intervention (PCI)-performing hospitals (20 patients per site), 13 (59%) wit...

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Veröffentlicht in:BMJ open 2017-09, Vol.7 (9), p.e016909-e016909
Hauptverfasser: Leonardi, Sergio, Marino, Marcello, Crimi, Gabriele, Maiorana, Florinda, Rizzotti, Diego, Lettieri, Corrado, Bettari, Luca, Zuccari, Marco, Sganzerla, Paolo, Tresoldi, Simone, Adamo, Marianna, Ghiringhelli, Sergio, Sponzilli, Carlo, Pasquetto, Giampaolo, Pavei, Andrea, Pedon, Luigi, Bassan, Luciano, Bollati, Mario, Camisasca, Paola, Trabattoni, Daniela, Brancati, Marta, Poli, Arnaldo, Panciroli, Claudio, Lettino, Maddalena, Tarelli, Giuseppe, Tarantini, Giuseppe, De Luca, Leonardo, Varbella, Ferdinando, Musumeci, Giuseppe, De Servi, Stefano
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Zusammenfassung:ObjectivesTo first explore in Italy appropriateness of indication, adherence to guideline recommendations and mode of selection for coronary revascularisation.DesignRetrospective, pilot study.Setting22 percutaneous coronary intervention (PCI)-performing hospitals (20 patients per site), 13 (59%) with on-site cardiac surgery.Participants440 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 measuresProportion 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.ResultsOf 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).ConclusionsUse 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.
ISSN:2044-6055
2044-6055
DOI:10.1136/bmjopen-2017-016909