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The dilemma of hard cases and patient centeredness

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by Farouc A. Jaffer, MD, PhD, FSCAI

We are faced with a difficult moment in the history of PCI. PCI rates are declining, but despite this decrease there remains a significant population of patients with CAD who are underserved — specifically, under-revascularized.

Farouc A. Jaffer

Recently, Stephen W. Waldo, MD, Robert W. Yeh, MD, and colleagues published data in Circulation showing that patients with CAD who were deemed ineligible for CABG had a sixfold increased risk for in-hospital death. One wonders if such high-risk patients are also being turned down for PCI.

A question I have is why we are not embracing the opportunity to perform PCI in our high-risk population most likely to benefit from revascularization. We know that higher-risk patients have the most to gain. In my opinion, there are multiple reasons.

1. The patients are complex.
2. The anatomy is complex.
3. Public reporting.
4. Reimbursement may not be commensurate with the time, resources and stress required by harder cases.

On May 6 during the Society for Cardiovascular Angiography and Interventions Scientific Sessions, Issam D. Moussa, MD, FSCAI, of First Coast Heart and Vascular Center in Jacksonville, Fla., summarized these additional factors as either cognitive biases (“not worth it” or “too high risk”) or limited expertise biases. Ajay J. Kirtane, MD, SM, FSCAI, from Columbia University Medical Center/New York-Presbyterian Hospital, further discussed the specific subgroup of chronic total occlusions (CTOs) and current resistance to performing CTO PCI, noting that the common stated reasons include “the lesion is harder to treat” or the misconception that “the risk-benefit ratio is unfavorable.”

So, how do we as a community address this unmet need? First, we need to acknowledge that some patients warrant treatment, even if we ourselves cannot treat them. If that is the case, we need to figure out how to get these patient treated, by asking for help from our colleagues within our institution or, if not sufficient, outside of our institution. Second, we must strive to get better at tough cases — calcification, bifurcations, unprotected left main, CTOs, hemodynamic support and so on. We need to ask our more experienced colleagues to help us, proctor us and teach us. We owe it to ourselves and, more importantly, we owe it to our patients.

What are your thoughts on embracing this unmet need? Let us know by commenting on this Eye on Intervention blog.

Reference:

Waldo SW, et al. Circulation. 2014;doi:10.1161/CIRCULATIONAHA.114.011541.

Farouc A. Jaffer, MD, PhD, FSCAI, is associate professor of medicine at Harvard Medical School and medical director of the CAD Program at Massachusetts General Hospital.

Disclosure: Jaffer reports no relevant financial disclosures.