Persistence of an Out-of-Date Cardiac Procedure

In 2006 a landmark clinical study, the Occluded Artery Trial (OAT), was published.  It was expected that its findings, namely the absence of any benefit using percutaneous coronary intervention (PCI) to open blocked coronary arteries 24 hours or longer after a heart attack (myocardial infarction or MI), would change medical practice.  Indeed, the results of the study were included in the 2007 American College of Cardiology and American Heart Association Guidelines for managing heart attacks.  Now there’s a new study to determine the impact of the OAT results and the 2007 Guidelines on clinical practice in the USA.  Specifically, it has concentrated on trends in monthly rates of ‘delayed’ PCI for blocked coronary vessels (i.e. more than 24 hours after occlusion) following the OAT publication and the 2007 Guidelines. The results are published in the Archives of Internal Medicine.

The investigators examined a registry of coronary angioplasty and stent-placing procedures in 28,780 patients at 896 US hospitals between 2005 and 2008.  Overall, there was no significant decline in the numbers of ‘delayed’-PCI monthly procedures after the publication of the OAT report in 2006 or after the 2007 Guidelines issued in 2007/2008.  Among those hospitals consistently reporting diagnostic catheterizations (i.e. without PCI at the time) there was a trend towards a decline in PCIs following the publications of the 2007 Guidelines.

It’s apparent that many (or most) cardiologists are still doing PCI procedures in patients 24 hours or more after a heart attack, suggesting a lack of awareness or familiarity with the Guidelines, or lack of agreement with the evidence supporting the Guidelines.  A cynic might also believe the fee-for-service health system could play a role in the continuation of an old practice that’s been shown to be of no benefit to the patient.  An anxious but relatively uneducated patient and relatives may also influence the cardiologist in a possibly difficult decision.