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How are interventional cardiologists making their treatment decisions during invasive coronary angiography?
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Introdução: As indicações de revascularização na doença arterial coronária têm critérios claramente identificados, definidos nas diretrizes publicadas. Embora existam vários estudos sobre a adequação das decisões realizadas por doente ou por procedimento, não há informações sobre a forma como os operadores estão a tomar as suas decisões de tratamento ao nível de uma lesão.
Objetivo: Avaliar como os operadores estão a tomar decisões de tratamento em lesões encontradas em doentes submetidos a angiografia coronária por doença arterial coronária. Os objetivos primários do estudo foram determinar os critérios de revascularização utilizados em cada lesão e a adequação dessas decisões de acordo com as indicações das diretrizes. Os desfechos secundários incluíram: 1) Análise se a hora do dia, dia da semana, os operadores, e eventos recentes dos operadores durante a intervenção interferem nas decisões de revascularização; 2) Análise se o sexo, a idade e a presença de DRC interferem na escolha do operador no tratamento das lesões.
População e Métodos: Estudo observacional, retrospetivo, unicentrico, coorte. Os dados foram obtidos de um banco de dados que inclui todos os doentes que realizaram angiografias coronárias em 2019. Foram recolhidas variáveis referentes às informações dos doentes e dos operadores.
Resultados: De um grupo inicial de 1.525 lesões significativas (em 544 doentes), 1.014 foram incluídas na análise. A maioria das decisões de tratamento (75,5%) foi feita de acordo com as recomendações das diretrizes e/ou foram consideradas “adequadas” com as informações disponíveis em cada caso. Os restantes 24,5% das decisões basearam-se apenas na opinião do operador. Se considerarmos apenas as decisões que não foram influenciadas por outros fatores anatómicos, clínicos ou circunstanciais, a percentagem de decisões não baseadas nas diretrizes foi de 34,1%. Se contabilizadas apenas as lesões não culpadas, a percentagem foi de 58,1%. Além disso, em 21,9% das lesões que foram para ICP, a decisão baseou-se exclusivamente na decisão do operador. Decisões não baseadas em diretrizes foram associadas a doentes mais velhos (mediana de 71 vs. 68 anos) e procedimentos mais longos (mediana de 60 vs. 54 minutos). As decisões não baseadas em diretrizes variaram de 12,6% a 37,3% para diferentes operadores e essas decisões tenderam a ser menos frequentes (2,0% vs. 4,4%) em operadores com um evento recente grave/fatal num procedimento realizado no mês anterior.
Conclusões: Ao nível das lesões, cerca de um quarto das decisões de tratamento em doentes com doença arterial coronária foi feita sem informações baseadas na evidência. Este número foi ainda maior (58%) quando consideradas apenas as lesões não culpadas por um SCA. Mais estudos são necessários para esclarecer o impacto das decisões não baseadas na evidência sobre o outcome dos doentes.
Introduction: Indications for revascularization in coronary artery disease have clearly identified criteria, defined in the published guidelines. Although there are several studies looking at the adequacy of these decisions per patient or per procedure, there is no information on the way operators are doing their treatment decisions at a lesion level. Purpose: To evaluate how operators are making treatment decisions at a lesion level in patients undergoing coronary angiography for coronary artery disease. The study’s primary endpoints were the criteria for revascularization used in each lesion and the adequacy of these decisions according to the guideline-based indications. Secondary endpoints included: 1) Analysis of whether the time of day, working day, operators and operators’ recent events during the intervention, interfere with revascularization decisions; 2) Analysis of whether the gender, age and presence of CKD interfere with the operator’s choice on treating lesions. Population and Methods: Observational, retrospective, single centre, cohort study. Data were obtained from a patient database that includes all patients who underwent coronary angiography in 2019. Variables concerning both patients’ and operators’ information were collected. Results: Of an initial group of 1525 significant lesions (in 544 patients), 1014 were included in the analysis. Most treatment decisions (75.5%) were compliant with the guideline-based recommendations and/or were considered “adequate” with the available information in each case. The remaining 24.5% decisions were only based on the operator’s opinion. If we only account for the decisions that were not influenced by other anatomical, clinical, or circumstantial factors, the percentage of non-guideline-based decisions was 34.1%. If only non-culprit lesions were accounted, this percentage was 58.1%. Additionally, in 21.9% of the lesions assigned to PCI, the decision was solely based on the operator’s decision. Non-guideline-based decisions were associated with older patients (median 71 vs. 68 years) and longer procedures (median 60 vs. 54 minutes). Non-guideline-based decisions ranged from 12.6% to 37.3% for different operators and these decisions tended to less frequent (2.0% vs. 4.4%) in operators with a recent severe/fatal event in a procedure performed by an operator in the previous month. Conclusions: At a lesion-level, around one quarter of the treatment decisions in coronary artery disease patients was made without evidence-based information. This number was even higher (58%) when only non-culprit lesions were considered. Further studies are needed in order to clarify the impact of the non-guideline-based decisions on patient outcomes.
Introduction: Indications for revascularization in coronary artery disease have clearly identified criteria, defined in the published guidelines. Although there are several studies looking at the adequacy of these decisions per patient or per procedure, there is no information on the way operators are doing their treatment decisions at a lesion level. Purpose: To evaluate how operators are making treatment decisions at a lesion level in patients undergoing coronary angiography for coronary artery disease. The study’s primary endpoints were the criteria for revascularization used in each lesion and the adequacy of these decisions according to the guideline-based indications. Secondary endpoints included: 1) Analysis of whether the time of day, working day, operators and operators’ recent events during the intervention, interfere with revascularization decisions; 2) Analysis of whether the gender, age and presence of CKD interfere with the operator’s choice on treating lesions. Population and Methods: Observational, retrospective, single centre, cohort study. Data were obtained from a patient database that includes all patients who underwent coronary angiography in 2019. Variables concerning both patients’ and operators’ information were collected. Results: Of an initial group of 1525 significant lesions (in 544 patients), 1014 were included in the analysis. Most treatment decisions (75.5%) were compliant with the guideline-based recommendations and/or were considered “adequate” with the available information in each case. The remaining 24.5% decisions were only based on the operator’s opinion. If we only account for the decisions that were not influenced by other anatomical, clinical, or circumstantial factors, the percentage of non-guideline-based decisions was 34.1%. If only non-culprit lesions were accounted, this percentage was 58.1%. Additionally, in 21.9% of the lesions assigned to PCI, the decision was solely based on the operator’s decision. Non-guideline-based decisions were associated with older patients (median 71 vs. 68 years) and longer procedures (median 60 vs. 54 minutes). Non-guideline-based decisions ranged from 12.6% to 37.3% for different operators and these decisions tended to less frequent (2.0% vs. 4.4%) in operators with a recent severe/fatal event in a procedure performed by an operator in the previous month. Conclusions: At a lesion-level, around one quarter of the treatment decisions in coronary artery disease patients was made without evidence-based information. This number was even higher (58%) when only non-culprit lesions were considered. Further studies are needed in order to clarify the impact of the non-guideline-based decisions on patient outcomes.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2022
Palavras-chave
Critérios de uso apropriado Decisões de tratamento Intervenção coronária percutânea Fractional Flow Reserve (FFR) Instantaneous wave-free ratio (iFR) Lesões Cardiopatia isquémica Cardiologia