Published in the January 2012 issue of Today’s Hospitalist
NEW CLINICAL GUIDELINES on percutaneous coronary intervention (PCI) will definitely affect how hospitalists care for cardiac patients.
According to James C. Blankenship, MD, vice chair of the PCI guideline writing committee for the Society for Cardiovascular Angiography and Interventions (SCAI), the guidelines call for a “heart team” made up of interventional cardiologists and cardiothoracic surgeons to jointly review a patient’s condition and coronary anatomy before recommending a course of treatment.
The rationale for the team approach for patients with unprotected left main or complex coronary artery disease, Dr. Blankenship says, is to encourage greater collaboration between surgeons and interventionalists when deciding whether a patient would be best served by bypass surgery or angioplasty.
Already, Dr. Blankenship points out, cardiologists discuss “the most difficult and complex cases” with surgeons. But “this guideline is suggesting it ought to be done on a more routine basis.”
The new recommendation reflects data showing that PCI and CABG surgery may be equally effective. Furthermore, for some patients, there isn’t enough evidence to recommend one definitively over the other.
What does all this mean for hospitalists? As Dr. Blankenship explains, it means that some very sick patients will go to the cath lab for angiography. But they will then be taken off the table immediately after that diagnostic procedure and admitted to the hospitalists’ service. Hospitalists should expect to care for these patients for some “variable” amount of time while cardiologists and cardiac surgeons agree on a course of revascularization.
Hospitalists might expect to see more patients in the period between their diagnostic procedure and their treatment, Dr. Blankenship says. Hospitalists “are going to be sitting there with a person who has three-vessel disease and they are going to be worried about the patient, while the cardiologist tries to find a cardiac surgeon who has time to talk with the patient.”
Hospitalists may also, he pointed out, “end up being the honest broker” for some patients. “There might be a cardiologist advocating for multi-vessel angioplasty, and the surgeon might be advocating for bypass surgery,” Dr. Blankenship says. “The role of the hospitalist may be to identify the patient’s values and help the patient make a decision in line with those values.”
The new guidelines, which were published online in November by the Journal of the American College of Cardiology, were issued jointly by the SCAI, the American College of Cardiology and the American Heart Association. One issue that the new guidelines address is post-procedural antiplatelet therapy.
The guidelines say, for instance, that there is no reason to put patients after PCI on adult-strength aspirin doses, even for a short period of time. Aspirin, dosed at 81 mg a day, should be used from the beginning.
“This is so much easier,” Dr. Blankenship says. “Starting immediately after the procedure, baby aspirin, continued indefinitely.”
The guidelines also stress the need for patients to comply with dual-antiplatelet therapy. Cardiologists should not perform PCI with coronary stenting if patients are not “likely to be able to tolerate and comply” with these month- to year-long drug regimens.
“If they know that patients are going to have a surgery next month or that they are on warfarin or just had a GI bleed, or that the patient can’t afford a couple thousand dollars a year,” says Dr. Blankenship, “hospitalists might want to point out to the cardiologist that this patient probably shouldn’t get a drug-eluting stent.”
The guidelines also state that any of the three antiplatelet drugs now approved by the FDA “clopidogrel (Plavix), prasugrel (Effient) and ticagrelor (Brilinta) “can be used “without preference for one over another,” he says.
Statins and PPIs
It is “reasonable” to give patients high-dose statins before PCI, Dr. Blankenship says. For patients not already taking a statin, it is appropriate to start a high dose before angioplasty.
Hospitalists should also make sure these patients are discharged with a statin prescription. “There is evidence that if a patient doesn’t go home from the hospital on a statin, you can’t expect that it will ever be started,” he says.
In terms of PPIs, Dr. Blankenship says the guidelines address concerns that these drugs, often prescribed prophylactically to prevent GI complications due to dual antiplatelet therapy, have been both over- and underused.
PPIs have been underused, he explains, because of concerns that they may inhibit the metabolism of clopidogrel. The guidelines make it clear, however, that evidence doesn’t bear this suspicion out.
In terms of overuse, the guidelines state that PPIs provide “no benefit” when given to patients at low risk of gastrointestinal bleeding, although the drugs are recommended for patients with a history of prior GI bleeding. PPIs may help patients on warfarin, steroids or NSAIDs, or those with H. pylori infections or of advanced age.
“If you don’t really need the PPIs, there is no point in using them,” Dr. Blankenship says. “But it is also true that they don’t really hurt anything either. We are not really worried about them inhibiting the metabolism of clopidogrel.”
The guidelines also make it clear, notes Dr. Blankenship, that “routine revascularization before noncardiac surgery should not be done if you have stable coronary artery disease.”
The guidelines also lay out the latest thoughts on what to do when a patient who had PCI unexpectedly needs noncardiac surgery. For such patients and for those with drug-eluting stents, “the guideline says stop the clopidogrel for the surgery,” he points out, “but continue aspirin and re-load with clopidogrel as soon as possible after surgery, maybe that night.”
Dr. Blankenship also says that the guidelines, importantly, stress that there is “no evidence” to support the Lovenox bridging strategy. “It is commonly done, but it is difficult and expensive,” he explains. “And there is not a shred of evidence that it is of any use.”
Quality and safety
Many patients should be discharged into cardiac rehabilitation programs, according to the new guidelines.
“Several studies show that cardiac rehab improves quality of life, decreases adverse events and decreases mortality,” Dr. Blankenship says. “It’s huge, and it’s often not done.” Hospitalists can play a key role. “When hospitalists are doing their discharge,” he notes, “they should be referring people to cardiac rehab.”
And because primary and elective PCI have gotten so much safer, the guidelines state that it is “reasonable” to allow hospitals that do not have cardiac surgery capabilities to perform emergency heart attack PCI. That’s as long as the hospital has an efficient, practiced plan for rapid emergency transport to a bigger facility.
However, the guidelines also note that small programs “those that do fewer than 200 caths a year “”should carefully consider whether they should offer the service,” Dr. Blankenship says. “That’s a nice way of saying that if the hospital is not doing at least 200 a year, perhaps it shouldn’t be doing them at all, unless it is in an underserved area.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.