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The majority of percutaneous coronary interventions (PCIs) performed in the U.S. are done for the right reasons, but when the treatment can be either medicine or a stent, the choice is too often a stent, researchers found.

Using criteria established two years ago, Paul Chan, MD, of Saint Luke's Mid America Heart and Vascular Institute in Kansas City, Mo., and colleagues report that for acute PCIs, 98.6% were appropriate, 0.3% had uncertain benefit, and 1.1% were inappropriate.

For elective procedures, however, 50.4% were appropriate, 38% had uncertain benefit, and 11.6% were inappropriate, which suggests "an important opportunity to examine and improve the selection of patients undergoing PCI in the nonacute setting," the researchers reported in the July 6 issue of the Journal of the American Medical Association.

In a statement, David Holmes, MD, of the Mayo Clinic in Rochester, Minn., noted that the appropriate use criteria for revascularization are suggested approaches to care.

"The ... criteria are not mandated but represent the knowledge and experience base present at the time when the criteria are written," said Holmes, who is the president of the American College of Cardiology (ACC), which sponsors the registry from which the study data were taken.

"The most important appropriate use approach is full communication of potential risks and benefits of a specific procedure to the patient and family," he said. "Clinical judgment and full patient understanding should always guide care. There may be times when what is best for the individual patient is at variance with either appropriate use criteria or guidance documents."

Six organizations -- the ACC, the Society for Cardiovascular Angiography and Interventions (SCAI), the Society of Thoracic Surgeons, the American Association for Thoracic Surgery, the American Heart Association, and the American Society of Nuclear Cardiology -- issued the appropriate use criteria in 2009.

Chan and his colleagues analyzed data from the CathPCI registry -- part of the larger National Cardiovascular Data Registry (NCDR) -- to determine the appropriateness of PCIs performed at 1,091 hospitals from July 1, 2009, to Sept. 30, 2010.

Of 500,154 PCIs, 71.1% were for acute indications -- ST-segment elevation MI (STEMI), non-STEMI, or unstable angina with high-risk features. The rest were elective.

The rate of inappropriate PCIs was low (1.1%) for acute indications, with little inter-hospital variation. All of these procedures involved asymptomatic patients with PCI performed more than 12 hours after symptom onset following a STEMI and without hemodynamic or electrical instability.

For elective PCIs, the rate of inappropriate procedures was 11.6%. Most of these procedures were in patients with no angina (53.8%), low-risk ischemia on stress testing (71.6%), or suboptimal anti-anginal therapy (95.8%). In addition, 94% did not have high-risk coronary anatomical findings.

There was substantial variation in the rate of inappropriate elective PCIs, ranging from 0% to 55% overall. The rate was 6% or less for the best-performing quarter of hospitals and 16.7% or higher for the worst-performing quarter.

Chan and his colleagues indicated that it is likely that clinician factors are responsible for the bulk of the inappropriate nonacute PCIs, which they said is supported by a previous analysis by their group showing wide variation in rates of agreement about appropriateness between individual cardiologists and the technical panel that crafted the appropriate use criteria.

"This suggests a need for further education of physicians about procedural appropriateness to improve patient selection in the nonacute setting," the researchers wrote.

Also, the high rate of uncertain indications for elective PCIs (38%) suggests that more research is needed to clarify the benefits of PCIs for those patients, they noted.

"Medicine is not black and white, so it's important to understand a procedure categorized as uncertain is just that -- the appropriateness could not be classified within the existing medical knowledge or the current structure of the appropriate use criteria," said co-author Gregory Dehmer, MD, of the Scott & White Clinic in Temple, Texas, in a statement.

"This underscores the interplay of art and science in medicine, and why there is no substitute for the physician-patient relationship to make the best choice together," said Dehmer, who is a past president of SCAI.

In their paper, Chan and his colleagues noted that some inappropriate or uncertain indications may actually be appropriate -- and some appropriate indications may be inappropriate -- when considering unique clinical and patient factors.

They acknowledged some limitations of the study, including the inability to evaluate the potential under-use of PCI using the registry, the exclusion of some procedures because of a lack of information on ischemia risk assessment results, and the possibility that hospitals inflated their rates of appropriate PCI by reporting more severe symptoms and stress test results.

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