A recent commentary published in the Journal of the American Medical Association raises concerns over the widespread use of ad hoc percutaneous coronary intervention (PCI) in stable patients, suggesting physicians instead take a "pause" after initial angiography to allow time to evaluate the most appropriate treatment.
Ad hoc PCI refers to instances in which coronary angiography and PCI are performed in the same setting. While quite common today even in stable patients, in the early days of PCI, procedures were generally performed days to weeks after diagnostic angiography, and ad hoc procedures were reserved for unique circumstances. The increasingly widespread use of ad hoc PCI is raising concerns, especially in light of recent clinical trials challenging the effectiveness of PCI compared to other treatment options (such as optimal medical therapy and CABG) in certain patient populations. As these trials raise important questions regarding the overuse or misuse of PCI, authors indicate it is even more important for patients and their physicians to take the time to consider all treatment options once the results of the initial angiography are known.
Therefore, the commentary advises cardiologists to limit their use of ad hoc PCI, and alternatively "pause" for a few days following diagnostic coronary angiography in stable patients. This break would allow the patient and physician to carefully evaluate and discuss the potential therapeutic options and corresponding risks, and even consult the referring physician who may have a long-standing relationship with the patient. While current payment systems often discourage performing diagnostic cath and PCI in two separate settings, the authors feel instituting this "time-out" between procedures is nevertheless crucial, as it can help ensure patients are receiving the most appropriate treatment based on the results of the diagnostic test (Nallamothu BK, Harlan MK, JAMA, December 2010 [subscription required]).