Assessing the association of appropriateness of coronary revascularization and 1-year clinical outcomes for patients with stable coronary artery disease in China

Abstract

Background: The Chinese appropriate use criteria (AUC) for coronary revascularization was released in 2016 to improve the use of coronary revascularization. This study aimed to evaluate the association between the appropriateness of coronary revascularization based on the Chinese AUC and 1-year outcomes in stable coronary artery disease (CAD) patients. Methods : We conducted a prospective, multi-center cohort study of stable CAD patients with coronary lesion stenosis ≥50%. After the classification of appropriateness based on Chinese AUC, patients were categorized into the coronary revascularization group or the medical therapy group based on treatment received. The primary outcome was a composite of death, myocardial infarction, stroke, repeated revascularization, and ischemic symptoms with hospital admission. Results: From August 2016 to August 2017, 6085 patients were consecutively enrolled. Coronary revascularization was associated with a lower adjusted hazard of 1-year major adverse cardiovascular and cerebrovascular events (MACCEs; hazard ratio [HR]: 0.62; 95% confidence interval [CI]: 0.45–0.86; P = 0.004) than medical therapy in patients with appropriate indications (n = 1617). No significant benefit in 1-year MACCEs was found after revascularization compared to after medical therapy in patients with uncertain indications (n = 2658, HR: 0.81; 95% CI: 0.52–1.25; P = 0.338) and inappropriate indications (n = 1810, HR: 0.80; 95% CI: 0.51–1.23; P = 0.308). Conclusions: In patients with appropriate indications according to Chinese AUC, coronary revascularization was associated with significantly lower risk of MACCEs at 1 year. No benefit was found in coronary revascularization in patients with inappropriate indications. Our findings provide evidence for using Chinese AUC to guide clinical decision-making. Clinical trial registration: NCT02880605. https://www.clinicaltrials.gov.

Effect of a standardised heart team protocol versus a guideline-based protocol on revascularisation decision stability in stable complex coronary artery disease: rationale and design of a randomised trial of cardiology specialists using historic cases

“…10 Prior data showed that 18.1% of the overall decision-making for patients with stable angina was classified as inappropriate based on a single disciplinary decision, especially among patients undergoing PCI. 32 The heart team, a medium of communication to integrate the input of numerous specialists, can help to minimise fragmented communication between specialists and eliminate specialist bias in the decision-making process. It was reported that heart team recommendations differed from those of the original treating interventional cardiologist in approximately one-third of cases.…”

“…35 In addition, appropriate revascularisation is associated with improved 1-year outcomes in patients with appropriate indications and has no benefit in those with uncertain or inappropriate indications. 19 Thus, we assume that revascularisation recommendations of dedicated heart teams organised by the standardised heart team protocol would be more stable and appropriate compared with those of general heart teams based on guideline principles, which leads to better clinical outcomes.…”

“…As the expertise of individual specialists is specific to their professional training and experience, cardiologists and surgeons prefer PCI or CABG, respectively 10. Prior data showed that 18.1% of the overall decision-making for patients with stable angina was classified as inappropriate based on a single disciplinary decision, especially among patients undergoing PCI 32. The heart team, a medium of communication to integrate the input of numerous specialists, can help to minimise fragmented communication between specialists and eliminate specialist bias in the decision-making process.…”

“…Sardari Nia et al reported patients treated for mitral valve disease based on a dedicated heart team decision have significantly higher survival than a general heart team, which illustrated the establishment of a dedicated heart team consisting of experienced specialists with adequate procedure volume benefits patient survival 35. In addition, appropriate revascularisation is associated with improved 1-year outcomes in patients with appropriate indications and has no benefit in those with uncertain or inappropriate indications 19. Thus, we assume that revascularisation recommendations of dedicated heart teams organised by the standardised heart team protocol would be more stable and appropriate compared with those of general heart teams based on guideline principles, which leads to better clinical outcomes.…”

“…We have randomly selected eligible cases from a prospective registry of consecutive patients who underwent coronary angiography between August 2016 and August 2017 (online supplemental figure 2). 19 All cases provided written informed consent at the time of registration and agreed to use their data for subsequent approved cardiovascular-related medical research. Definitions and inclusion/exclusion criteria of cases can be seen in online supplemental methods.…”