Percutaneous Coronary Intervention in Stable Coronary Heart Disease -Is Less More?

[Improving Postgraduate Medical Training In Germany: A Proposal]

Postgraduate (vocational, residency) training in Germany is regulated by the Physicians' Chamber in each federal state. Although training requirements are specified in detail by regulatory documents, young doctors are left on their own to find training posts and suitable learning experiences. There are no programmes in place to support trainees nor to identify the need of the health care system regarding the composition of its medical workforce. Hospitals and practices pay salaries to physicians in training from funding obtained for services they provide. We propose a systematic and continuing process of identifying gaps in the workforce. Disciplines with a lack of qualified doctors will be supported by additional funds directed to practices and hospitals. Regional rotation schemes will coordinate and improve the quality of training. Apart from an administrative overhead, this system of regulation will not need additional resources because a limited part of current budgets will be explicitly channelled into salaries for trainees in specialties for which there is a higher need than into others.

Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure

BACKGROUND

The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study.

METHODS

General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis.

RESULTS

Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees.

CONCLUSIONS

Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.

Guideline adherence in the use of coronary angiography in patients presenting at the emergency department without myocardial infarction - Results from the German ENLIGHT-KHK project

Background

For patients with acute myocardial infarction (AMI), direct coronary angiography (CA) is recommended, while for non-AMI patients, the diagnostic work-up depends on clinical criteria. This analysis provides initial prospective German data for the degree of guideline-adherence (GL) in the use of CA on non-AMI patients presenting at the emergency department (ED) with suspected acute coronary syndrome (ACS) according to the 2015 ESC-ACS-GL. Furthermore the implications of the application of the 2020 ESC-ACS-GL recommendations were evaluated.

Methods

Patient symptoms were identified using a standardized questionnaire; medical history and diagnostic work-up were acquired from health records. In accordance with the 2015 ESC-ACS-GL, CA was considered GL-adherent if intermediate risk criteria (IRC) were present or non-invasive, image-guided testing (NIGT) was pathological.

Results

Between January 2019 and August 2021, 229 patients were recruited across seven centers. Patients presented with chest pain, dyspnea, and other symptoms in 66.7%, 16.2% and 17.1%, respectively, were in mean 66.3 ± 10.5 years old, and 36.3% were female. In accordance with the 2015 ESC-ACS-GL, the use of CA was GL-adherent for 64.0% of the patients. GL-adherent compared to non-adherent use of CA resulted in revascularization more often (44.5% vs. 17.1%, p < 0.001). Applying the 2020 ESC-ACS-GL, 20.4% of CA would remain GL-adherent.

Conclusions

In the majority of cases, the use of CA was adherent to the 2015 ESC-ACS-GL. With regard to the 2020 and 2023 ESC-ACS-GL, efforts to expand the utilization of NIGT are crucial, especially as GL-adherent use of CA is more likely to result in revascularization.(German Clinical Trials Register DRKS00015638; https://drks.de/search/de/trial/DRKS00015638; (registration date: 19 February 2019)).

Advancements in Percutaneous Coronary Intervention Techniques: A Comprehensive Literature Review of Mixed Studies and Practice Guidelines

Percutaneous coronary intervention (PCI) is a widely used therapy for coronary artery disease (CAD), but it carries risks and complications. Adhering to evidence-based practice guidelines is crucial for optimal outcomes. This review compares the recommendations of the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) and 2018 European Society of Cardiology (ESC) guidelines for coronary artery revascularization and discusses emerging trends and novel devices in PCI. A comprehensive literature review of mixed studies, clinical trials, and guidelines was conducted. Intravascular imaging, including intravascular ultrasound and optical coherence tomography, for stent optimization, is also recommended when feasible. However, differences reflecting variations in evidence quality interpretation and applicability were identified. Furthermore, novel devices and technologies with the potential for improving outcomes were highlighted, but their safety and efficacy compared to standard-of-care techniques require further evaluation through extensive randomized trials. Clinicians should stay updated on advancements and personalize treatment decisions based on individual patient factors. Future research should address evidence gaps and barriers to adopting innovative devices and techniques. This review provides recommendations for clinical practice, emphasizing the need to remain current with the evolving landscape of PCI to optimize patient outcomes. The discoveries provide valuable counsel for the deliberation of clinical interventions and prospective inquiries within the realm of interventional cardiology. Overall, the review underscores the importance of evidence-based practice and ongoing advancements in PCI for CAD management.

Popular procedures without evidence of benefit: A case study of percutaneous coronary intervention for stable coronary artery disease

Despite limited benefit, percutaneous coronary intervention (PCI) remains a common procedure that is often performed for uncertain or inappropriate indications in patients with stable coronary artery disease (CAD). PCI cases per capita have increased year-over-year in most European countries, and many have higher rates than the U.S. Meanwhile, first-line therapy such as optimal medical therapy (OMT) and lifestyle changes, continue to be under-utilized. This article reviews the evidence on use of PCI in stable CAD. Specifically, we analyzed randomized control trials, systematic reviews, appropriate use criteria, and professional society guidelines that examine the risks and benefits of PCI compared to OMT. We then highlight utilization patterns as well as interventions that better align current practice with evidence-based care.

Greater Nursing Role for Enhanced Post-Percutaneous Coronary Intervention Management

Percutaneous coronary intervention (PCI) has increasingly been used in management of coronary artery diseases (CAD). Coupled that with an increasing incidence rate of CAD has augmented the hospital burden with consequential post-PCI patient management problems and dissatisfaction. Nursing care has a key role to play in upgrading the healthcare services and raising patients’ satisfaction through enhanced patient education and engagement. In this regard, nursing-led intervention has shown some success in three main domains: risk reduction; psychological improvement; and quality of life. Urgent efforts are needed to formulize a structured follow-up with enhanced nursing role in post-PCI management to raise quality of healthcare.

Inhibition of Platelet Aggregation After Coronary Stenting in Patients Receiving Oral Anticoagulation

BACKGROUND

Approximately 18% of patients with atrial fibrillation undergo a percutaneous coronary intervention (PCI) to treat coronary heart disease. Pharmacological anticoagulation in patients with atrial fibrillation and PCI involves a trade-off of potential ischemic and hemorrhagic complications.

METHODS

This review is based on pertinent publications that were retrieved by a selective literature search, including current guidelines and recommendations.

RESULTS

Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor protects against stent thrombosis, but not against thromboembolic stroke. In contrast, oral anticoagulation does provide effective prevention against stroke during atrial fibrillation. Combining DAPT with oral anticoagulation (triple therapy) over the long term, as has been recommended to date, carries an elevated risk of hemorrhage. In a randomized controlled trial, 44% of patients with atrial fibrillation receiving triple therapy sustained a hemorrhagic event, compared to 19.4% of patients receiving dual therapy. A meta-analysis has shown that clinically relevant hemorrhage is less common under combined treatment with one of the new oral anticoagulants (NOAC) and a single antiplatelet drug than under triple therapy including a vitamin K antagonist (hazard ratio, 0.56; 95% confidence interval 0.39; 0.80]), but no significant difference was found with respect to stent thrombosis, myocardial infarction, or overall mortality.

CONCLUSION

After coronary stent implantation, dual therapy with a NOAC and a P2Y12 inhibitor is recommended, subsequent to triple therapy given only during the peri-interventional period.