Most veterans who had stress testing within 2 years after PCI had obstructive CAD symptoms
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Among veterans who underwent post-elective PCI stress testing before the guideline-recommended 2 years due to chest pain, most had symptoms consistent with obstructive CAD, according to data published in JAMA Network Open.
“Up to 50% of patients undergo stress testing within 2 years of receiving PCI,” Vinay Kini, MD, MSHP, general cardiologist and health services researcher at Weill Cornell Medicine, told Healio. “This has prompted concerns about overuse, since clinical guidelines suggest that only patients with symptoms concerning for angina should receive testing. In fact, post-PCI stress testing is a commonly used measure of overuse, even though it is not well understood what proportion of patients who get tested have symptoms, and thus how many of these stress tests might be clinically indicated.
“Using chart review, we found that the vast majority of patients in our study who underwent stress testing within 2 years of elective PCI had symptoms concerning for angina at the time of testing,” Kini told Healio. “This suggests that the patients in our study were receiving stress tests appropriately, in accordance with clinical guidelines. Thus, measuring post-PCI stress testing, without accompanying data on patient symptoms, does not seem to be a valid measure of overuse.”
On the basis that much of the stress testing performed within 2 years after PCI may be low value and not indicated by the 2013 guideline, researchers conducted the present analysis using claims data from the U.S. Department of Veterans Affairs Clinical Assessment, Reporting and Tracking program to determine the proportion of patients who underwent early post-PCI stress testing, how many had symptoms consistent with CAD and the timing of these tests.
Investigating early post-PCI stress testing overuse
Researchers included 3,705 consecutive patients with stable CAD (mean age, 66 years; 99% men; 86% white) who underwent elective PCI and stress testing within 2 years at 64 VA centers between November 2013 and October 2015.
Within this cohort, approximately 24.7% underwent a stress test within 2 years post-PCI, of which 79.7% experienced symptoms consistent with obstructive CAD. The majority of symptoms were chest pain (74.3%) and dyspnea (50.1%).
Compared with asymptomatic patients, symptomatic patients were more likely to receive two or more antianginal prescriptions (30.2% vs. 10.7%; P = .03) and to have single-vessel obstructive CAD on their index coronary CT (60.1% vs. 40%; P = .002).
Additionally, the overall proportion of stress tests performed within 2 years post-PCI with ischemia-positive results was similar among symptomatic and asymptomatic groups (45.1% vs. 36.9%; P = .39).
Across all 67 VA sites in the study, the proportion of patients with symptomatic CAD who underwent stress testing ranged from 67.7% to 100% (median of 93.3%). At nearly half of all VA sites included in the analysis, 100% of post-PCI stress testing was performed in symptomatic patients, according to the researchers.
Researchers reported an overall increase in stress testing between 60 days and 2 years post-PCI.
Overuse concerns potentially overstated
“Other measures of overuse are commonly used in the literature, but have not been validated. We believe that similar studies should be performed to understand which overuse measures can be accurately identified without in-depth chart review,” Kini told Healio. “Our study was performed in the VA, and we would like to see whether the results are similar in other populations, such as among Medicare fee-for-service beneficiaries.”
For more information:
Vinay Kini, MD, MSHP, can be reached at vuk9003@med.cornell.edu.
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