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Locating obstructive CAD varies among hospitals
Douglas PS. J Am Coll Cardiol. 2011;58:801-809.
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The rate of finding obstructive coronary artery disease at elective coronary angiography varied widely among hospitals and was associated with patient selection and pre-procedure assessment strategies, according to a study.
The researchers performed a retrospective analysis of 565,504 patients from 691 US hospitals who did not have a history of MI or revascularization and underwent elective coronary angiography. They used CathPCI registry data from 2005 to 2008 and evaluated the rate of obstructive CAD.
According to data, there was variation among the hospitals in the rate of obstructive CAD, with rates ranging from 23% to 100% (median, 45%). These rates were consistent from year to year. Sites that had lower rates of finding obstructive CAD were more likely to perform procedures on younger patients, women, blacks and outpatients.
Researchers also found that sites with lower rates studied more patients with a lower Framingham risk and patients with no or atypical symptoms. These patients were less likely to have stable angina symptoms, a positive stress test before coronary angiography or both, and were less likely to have been prescribed cardiac medications before angiography.
Additionally, the rate of CAD was lower at facilities with small-volume cath labs.
This is an interesting study because, for the first time, researchers looked at a very large dataset in a retrospective analysis of more than a half-million patients without history of MI or revascularization. What they observed, as one would anticipate, is a lot of variability in the findings of this disease.
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What is of interest is how they were actually able to identify those institutions where the prevalence of obstructive CAD was low. This is important because we do heart catheterizations with the objective to treat. We would like our rates of CAD to be higher after we send our patients to the cath lab, because otherwise, one would argue that we do heart catheterizations unnecessarily in many patients. One of the findings that is surprising is that institutions did these procedures on younger patients, those with less risk factors and those without typical symptoms or without a positive stress test. When you look at these criteria, there is clearly a problem in the selection of the patients going to the cath lab.
What was also interesting is that the pattern of these findings was pretty consistent over time. So, I see this analysis as the basis for a quality improvement program. Clearly, there are hospitals in the United States where heart catheterizations are being performed with very low rates of finding obstructive CAD, and this teaches us that perhaps certain institutions should implement better tools for risk stratifying their patients before sending them to the cath lab.
– Dominick J. Angiolillo,
MD
Cardiology Today Intervention Editorial Board
member
Disclosure: Dr. Angiolillo reports no relevant financial
disclosures.