Despite guideline recommendations for a heart team approach, ad hoc percutaneous coronary intervention (PCI) is surprisingly common in stable patients with multivessel (MV) or unprotected left main (LM) disease, according to new registry data. The study, published online Monday and in the July 24 issue of JACC: Cardiovascular Interventions, notes that there is very little information about the use of ad hoc PCI in stable patients with MV disease or unprotected left main LM disease patients, for whom a heart team approach is recommended. “Several studies have found that a high percentage of PCI patients undergo ad hoc PCI and that outcomes for those patients are not substantially different from outcomes for other PCI patients,” said the study authors, led by Edward L. Hannan, PhD, from the State University of New York, Albany. “However, one concern that has not been addressed in those studies is the extent to which ad hoc PCI may preclude the option to choose another treatment that may be preferable such as optimal medical therapy for patients with milder asymptomatic CAD or coronary artery bypass graft (CABG) surgery for patients with complex multivessel CAD.” The research team cited the latest (2011) ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, in which CABG surgery is a Class 1 recommendation for patients with LM disease, whereas PCI is a Class 2a, 2b, or 3 recommendation depending on other factors. “An alternative to ad hoc PCI is a heart team approach in which caregivers and the patient share the decision,” they said, noting that after diagnostic angiography, discussions about the pros and cons of alternative treatments in conjunction with patient preferences contribute to the decision. Study setup Hannan and colleagues investigated the extent of ad hoc PCI utilization for patients with MV disease or LM disease, with an objective to explore inter-hospital variation in ad hoc PCI utilization for those patients. They used data from New York state’s cardiac registries to examine the use and variation in use of ad hoc PCI for MV/ LM disease as a percentage of all MV/LM PCIs and revascularizations (PCIs plus CABG procedures) during 2018 to 2019 in New York. A total of 8,196 PCI patients were included in the study, while 10,122 isolated (no other major open heart procedures performed) CABG surgery patients were also identified for inclusion at the same time period as the PCI patients. The main outcome studied was the choice of procedure (ad hoc PCI, delayed [not ad hoc] PCI, or isolated CABG surgery). All patients with two-vessel disease with proximal left anterior descending (PLAD) artery disease, three-vessel disease and unprotected LM disease were classified according to whether they underwent ad hoc PCI, delayed (not ad hoc) PCI, or CABG surgery, said the team. Key findings In total, 6,425 of the 8,196 stable PCI patients with MV/LM disease (78.4%) underwent ad hoc PCI. This percentage ranged from 58.7% for patients with unprotected LM disease to 85.4% for patients with two-vessel PLAD disease, reported the team. “When patients with myocardial infarction with an onset time between 1 and 7 days were also excluded, the ad hoc percentage decreased slightly to 77.2% for all patients and a range of 56.2% for patients with unprotected LM disease to 85.0% for patients with 2-vessel PLAD disease,” they said. However, when all revascularizations (PCI plus CABG surgery) were used as a denominator instead of all PCIs, ad hoc PCIs comprised 35.1% for all patients. “This percentage ranged from 63.9% for patients with 2-vessel PLAD disease to 11.5% for patients with unprotected LM disease, with the percentage for patients with 3-vessel disease in between the other percentages (32.4%),” reported Hannan and colleagues, adding that patients with diabetes and patients with compromised LVEF (≤35%) were less likely to have undergone ad hoc PCI as a percentage of all revascularizations than their counterparts (31.0% vs 38.6%; P < 0.0001 and 29.0% vs 36.0%; P < 0.0001, respectively) and that this was the case for two-vessel PLAD disease and three-vessel disease groups but not for patients with unprotected LM disease. “Ad hoc PCIs occur frequently even among patients with MV/LM disease,” they reported. “This is particularly true among patients with 2-vessel PLAD disease.” Furthermore, the frequency of ad hoc PCIs is lower, but still high, among patients with diabetes and low ejection fraction and higher in hospitals without surgery on-site (SOS). “Given the magnitude of hospital- and physician-level variation in the use of ad hoc PCIs for such patients, consideration should be given to a systems approach to achieving heart team consultation and shared decision making that is consistent for SOS and non-SOS hospitals,” concluded the authors. Lack of consensus? Writing in an accompanying editorial, James C. Blankenship, MD, MHCM, and Krishna Patel, MD, from the University of New Mexico, warned that the rate of ad hoc PCI is “surprisingly high compared to what might be expected, considering guideline recommendations for the heart team approach.” The editorialists added that although some variation among hospitals and individual physicians in rates of ad hoc PCI may be expected because of local expertise and practice styles, variation of the magnitude observed in this cohort clearly reflects a lack of consensus about how to employ the heart team approach. “Why should we be concerned about the findings of this study? First, patients deserve the freedom to choose the strategy that provides the best odds of good outcomes,” they said. “Second, in this era of patient-oriented decision making, patients deserve to have time to evaluate options in an unhurried environment where they can consult with family and experts from various disciplines to arrive at a decision that suits them best. Both of these may be compromised by ad hoc PCI.” The expert commentators warned that that economic, organizational and psychological factors all conspire to support ad hoc PCI but noted that past criticisms of ad hoc PCI have had “seemingly little effect,” and that ad hoc approaches are seemingly common even in high-risk anatomical subsets, where guidelines would recommend a heart team approach rather than ad hoc PCI. Sources: Hannan EL, Zhong Y, Cozzens K, et al. Ad Hoc Percutaneous Coronary Intervention in Stable Patients With Multivessel or Unprotected Left Main Disease. JACC Cardiovasc Interv 2023;16:1733-1742. Blankenship JC, Patel K. High Rates of Ad Hoc PCI May Mandate a Modified Heart Team Approach. JACC Cardiovasc Interv 2023;16:1743-1745. Image Credit: Franz – stock.adobe.com