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Appropriateness of percutaneous coronary interventions in patients with ischemic heart disease in Italy: The APACHE Pilot study

Session Poster session 1

Speaker Sergio Leonardi

Event : ESC Congress 2017

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Coronary Artery Disease (Chronic)
  • Session type : Poster Session

Authors : SL Leonardi (Pavia,IT), G Musumeci (Cuneo,IT), L De Luca (Rome,IT), F Varbella (Rivoli,IT), M Lettino (Rozzano,IT), G Tarantini (Padua,IT), G Tarelli (Rozzano,IT), D Trabattoni (Monzino,IT), G Crimi (Pavia,IT), D Rizzotti (Pavia,IT), C Lettieri (Mantova,IT), M Marino (Crema,IT), F Maiorana (Pavia,IT), L Bettari (Cremona,IT), S De Servi (Milan,IT)

Authors:
S.L. Leonardi1 , G. Musumeci2 , L. De Luca3 , F. Varbella4 , M. Lettino5 , G. Tarantini6 , G. Tarelli5 , D. Trabattoni7 , G. Crimi1 , D. Rizzotti1 , C. Lettieri8 , M. Marino9 , F. Maiorana1 , L. Bettari10 , S. De Servi11 , 1Foundation IRCCS Polyclinic San Matteo - University of Pavia - Pavia - Italy , 2Santa Croce E Carle Hospital - Cuneo - Italy , 3S.Giovanni Evangelista Hospital-Tivoli - Rome - Italy , 4Degli Infermi Hospital - Rivoli - Italy , 5Clinical Institute Humanitas IRCCS - Rozzano - Italy , 6University Hospital of Padova - Padua - Italy , 7Centro Cardiologico Monzino-IRCCS - Monzino - Italy , 8Hospital Carlo Poma - Mantova - Italy , 9Maggiore Hospital of Crema - Crema - Italy , 10Hospital of Cremona - Cremona - Italy , 11IRCCS Multimedica of Milan - Milan - Italy ,

On behalf: APACHE Investigators

Citation:
European Heart Journal ( 2017 ) 38 ( Supplement ), 183

Background: Real world data on appropriateness of indication, adherence to guideline recommendations, and mode of selection for coronary revascularization in Europe are scarce.

Purpose: We designed the APpropriAteness of percutaneous Coronary interventions in patients with ischemic HEart disease – APACHE Pilot study to first explore the degree of appropriateness of indication of PCI, multi-disciplinary decision-making processes, and implementation of key guideline recommendations in patients undergoing coronary revascularization in Italy.

Methods: We analyzed data from twenty-two Italian hospitals (20 patients/site), thirteen (59%) with on-site cardiac surgery. 440 patients who received percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) or non-ST elevation acute coronary syndrome were independently selected in a 4:1 ratio with half diabetics without site personnel involvement in the selection of the cases identified to minimize selection bias. Appropriateness of PCI indication was evaluated using validated appropriate use scores (AUS). An angiographic core laboratory verified site-reported coronary anatomy and identified borderline coronary stenoses. In patients with stable CAD adherence to the following ESC recommendations was examined: a) % of patients with complex coronary anatomy (including lesions of the left main, proximal LAD and/or three-vessel CAD) treated after heart-team discussion; b) % of fractional flow reserve-guided PCI for borderline stenoses in patients without documented ischemia; c) % of patients receiving guideline-directed medical therapy at the time of PCI. Finally, pre-test probability (PTP) of CAD in stable CAD patients without known coronary anatomy and its association with test of ischemia use was examined. The study is registered on ClinicalTrial.Gov ID: NCT02748603.

Results: Of all PCIs, 35.2% were classified as appropriate, 43.4% as uncertain, and 12.5% as inappropriate. Median (25th, 75th) AUS was 6 (5,7). Median PTP of CAD in stable CAD patients was 69% (78% intermediate PTP, 22% high PTP, no patient with low PTP). The use of provocative tests of ischemia was similar (p=0.71) in patients with intermediate (n=140, 63%) and with high PTP (n=40, 66%).

In patients with stable CAD (n=352) guideline adherence to the 3 recommendations explored was: a) 11%; b) 25%; c) 23%. AUS was higher in patients evaluated by the heart team as compared to patients who were not [7 (6,8) vs 5 (4,7); P=0.001] (Figure). Most hospitals (n=12, 54%) did not have either a heart-team institutional protocol or regularly planned heart-team meetings.

Conclusions: Use of heart-teams approaches and adherence to guideline recommendations on coronary revascularization in a real world setting is limited. This pilot study documents the feasibility of measuring appropriateness and guideline adherence in clinical practice and identifies substantial opportunities for quality improvement.

AUS by Diabetes, With and W/O HeartTeam

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