APpropriAteness of percutaneous Coronary interventions in patients with ischaemic HEart disease in Italy

Sergio Leonardi; Marcello Marino; Gabriele Crimi; Florinda Maiorana; Diego Rizzotti; Corrado Lettieri; Luca Bettari; Marco Zuccari; Paolo Sganzerla; Simone Tresoldi; Marianna Adamo; Sergio Ghiringhelli; Carlo Sponzilli; Giampaolo Pasquetto; Andrea Pavei; Luigi Pedon; Luciano Bassan; Mario Bollati; Paola Camisasca; Daniela Trabattoni; Marta Brancati; Arnaldo Poli; Claudio Panciroli; Maddalena Lettino; Giuseppe Tarelli; Giuseppe Tarantini; Leonardo De Luca; Ferdinando Varbella; Giuseppe Musumeci; Stefano De Servi

doi:10.1136/bmjopen-2017-016909

APpropriAteness of percutaneous Coronary interventions in patients with ischaemic HEart disease in Italy

Sergio Leonardi, Marcello Marino, Gabriele Crimi, Florinda Maiorana, Diego Rizzotti, Corrado Lettieri, Luca Bettari, Marco Zuccari, Paolo Sganzerla, Simone Tresoldi, Marianna Adamo, Sergio Ghiringhelli, Carlo Sponzilli, Giampaolo Pasquetto, Andrea Pavei, Luigi Pedon, Luciano Bassan, Mario Bollati, Paola Camisasca, Daniela TrabattoniMarta Brancati, Arnaldo Poli, Claudio Panciroli, Maddalena Lettino, Giuseppe Tarelli, Giuseppe Tarantini, Leonardo De Luca, Ferdinando Varbella, Giuseppe Musumeci, Stefano De Servi

Centro Cardiologico Monzino

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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.

Original language	English
Pages (from-to)	e016909
Journal	BMJ Open
Volume	7
Issue number	9
DOIs	https://doi.org/10.1136/bmjopen-2017-016909
Publication status	Published - Sep 5 2017

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Leonardi, S., Marino, M., Crimi, G., Maiorana, F., Rizzotti, D., Lettieri, C., Bettari, L., Zuccari, M., Sganzerla, P., Tresoldi, S., Adamo, M., Ghiringhelli, S., Sponzilli, C., Pasquetto, G., Pavei, A., Pedon, L., Bassan, L., Bollati, M., Camisasca, P., ... De Servi, S. (2017). APpropriAteness of percutaneous Coronary interventions in patients with ischaemic HEart disease in Italy. BMJ Open, 7(9), e016909. https://doi.org/10.1136/bmjopen-2017-016909

APpropriAteness of percutaneous Coronary interventions in patients with ischaemic HEart disease in Italy. / 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.

In: BMJ Open, Vol. 7, No. 9, 05.09.2017, p. e016909.

Research output: Contribution to journal › Article

Leonardi, S, Marino, M, Crimi, G, Maiorana, F, Rizzotti, D, Lettieri, C, Bettari, L, Zuccari, M, Sganzerla, P, Tresoldi, S, Adamo, M, Ghiringhelli, S, Sponzilli, C, Pasquetto, G, Pavei, A, Pedon, L, Bassan, L, Bollati, M, Camisasca, P, Trabattoni, D, Brancati, M, Poli, A, Panciroli, C, Lettino, M, Tarelli, G, Tarantini, G, De Luca, L, Varbella, F, Musumeci, G & De Servi, S 2017, 'APpropriAteness of percutaneous Coronary interventions in patients with ischaemic HEart disease in Italy', BMJ Open, vol. 7, no. 9, pp. e016909. https://doi.org/10.1136/bmjopen-2017-016909

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. / APpropriAteness of percutaneous Coronary interventions in patients with ischaemic HEart disease in Italy. In: BMJ Open. 2017 ; Vol. 7, No. 9. pp. e016909.

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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.",

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author = "Sergio Leonardi and Marcello Marino and Gabriele Crimi and Florinda Maiorana and Diego Rizzotti and Corrado Lettieri and Luca Bettari and Marco Zuccari and Paolo Sganzerla and Simone Tresoldi and Marianna Adamo and Sergio Ghiringhelli and Carlo Sponzilli and Giampaolo Pasquetto and Andrea Pavei and Luigi Pedon and Luciano Bassan and Mario Bollati and Paola Camisasca and Daniela Trabattoni and Marta Brancati and Arnaldo Poli and Claudio Panciroli and Maddalena Lettino and Giuseppe Tarelli and Giuseppe Tarantini and {De Luca}, Leonardo and Ferdinando Varbella and Giuseppe Musumeci and {De Servi}, Stefano",

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doi = "10.1136/bmjopen-2017-016909",

language = "English",

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T1 - APpropriAteness of percutaneous Coronary interventions in patients with ischaemic HEart disease in Italy

AU - Leonardi, Sergio

AU - Marino, Marcello

AU - Crimi, Gabriele

AU - Maiorana, Florinda

AU - Rizzotti, Diego

AU - Lettieri, Corrado

AU - Bettari, Luca

AU - Zuccari, Marco

AU - Sganzerla, Paolo

AU - Tresoldi, Simone

AU - Adamo, Marianna

AU - Ghiringhelli, Sergio

AU - Sponzilli, Carlo

AU - Pasquetto, Giampaolo

AU - Pavei, Andrea

AU - Pedon, Luigi

AU - Bassan, Luciano

AU - Bollati, Mario

AU - Camisasca, Paola

AU - Trabattoni, Daniela

AU - Brancati, Marta

AU - Poli, Arnaldo

AU - Panciroli, Claudio

AU - Lettino, Maddalena

AU - Tarelli, Giuseppe

AU - Tarantini, Giuseppe

AU - De Luca, Leonardo

AU - Varbella, Ferdinando

AU - Musumeci, Giuseppe

AU - De Servi, Stefano

PY - 2017/9/5

Y1 - 2017/9/5

N2 - 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.

AB - 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.

KW - Journal Article

U2 - 10.1136/bmjopen-2017-016909

DO - 10.1136/bmjopen-2017-016909

M3 - Article

VL - 7

SP - e016909

JO - BMJ Open

JF - BMJ Open

SN - 2044-6055

IS - 9

ER -

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