Coronary angiography in non intervention centers: is there a future? A. van der Sluis, cardiologist Deventer Ziekenhuis - Deventer

Transcription

1 Coronary angiography in non intervention centers: is there a future? A. van der Sluis, cardiologist Deventer Ziekenhuis - Deventer

2 No disclosures

3 Why is it an issue in the first place? Organization in the Netherlands differs from most other European countries Publication Achmea guide Zorginkoopbeleid 2016, Medisch Specialistische Zorg Publication 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

4 Why is it an issue in the first place? Background Organization in the Netherlands differs from most other European countries o Nearly all general hospitals have CCU and EHH facilities o Nearly all general hospitals have catheterization laboratories o Only high volume PCI centers that have to adhere to strict volume criteria

5 Myocardial infarction: mortality in European countries 2013 Source: Eurostat, 2016

6 Publication Achmea guide Zorginkoopbeleid 2016, Medisch Specialistische Zorg Objective: o In the diagnostic process of coronary artery pathology optimal use is made of non invasive diagnostic techniques (i.e. Ca score, CT coronary angiography, MIBI scan, PET- CT scan). No diagnostic coronary angiography is performed, if there is no possibility to perform an intervention (dotter, stent) in the same session.

7 Publication Achmea guide Zorginkoopbeleid 2016, Medisch Specialistische Zorg Objective: o In the diagnostic process of coronary artery pathology optimal use is made of non invasive diagnostic techniques (i.e. Ca score, CT coronary angiography, MIBI scan, PET- CT scan). No diagnostic coronary angiography is performed, if there is not a possibility to perform an intervention (dotter, stent) in the same session. Reaction NVVC: o It is not clear to us based on which information you have come to this objective. More importantly, this objective is in conflict with current consensus, ESC guidelines and daily practice. Between the moment of a diagnostic heart catheterization and a possible intervention (only in 40% of patients a PCI is performed eventually) a heart team meeting should take place. Implementation of this objective will have major consequences, not only for centers performing diagnostic heart catheterizations, but for nearby interventional centers as well.

8 Publication Achmea guide Zorginkoopbeleid 2016, Medisch Specialistische Zorg Reaction IGZ o The inspector is under the impression, that by forcing hospitals to subject their patients to a combined diagnostic and therapeutical procedure, no consideration is given to the priority which is given in the Netherlands to correct assessment of indication and desicion making in a multidisciplinary team (heart team) according to current guidelines. o No prospective risk analysis is provided o No support ZiNL theme: diagnostics in chest pain patients from general practitioner to cath. lab

9 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

10 Current situation Elective patients: diagnostic (invasive) procedure in own hopital STEMI: direct transfer to intervention center Acute chest pain: transfer to nearest hospital o Diagnostic process and risk assessment (as yet not possible at FMC) o Very high risk NSTEMI-ACS directly transferred to intervention center o Medical stabilization o If indicated coronary angio o Heart team decision if warranted

11 Considerations to change current practice Improvements in quality of care o Based on scientific evidence o Initiative for change from the NVVC Logistical arguments Financial reasons

12 Arguments concerning quality of care Elective patients No studies comparing outcome for elective catheterization in out-patients o Complication rate is low o Differences in MACE are highly unlikely Better quality of images and higher success rate in experienced hands o Only likely if procedures would be restricted to high volume operators

13 Arguments concerning quality of care NSTEMI-ACS ESC guidelines 2015 advocate coronary angiography/percutaneous intervention for high risk ACS patients (GRACE score > 140, positive troponin, dynamic ecg changes) within 24 hours. Amendment NVVC working group on ACS: o No new scientific evidence supporting the change in guidelines Evidence supporting early invasive strategy is based on meta analyses of randomized trials and retrospective analysis of the Acuity trial. The benefit of early intervention in TIMACS was a subgroup analysis, the primary end point was negative. The meta analyses showed no benefit in mortality, non fatal MI or bleeding, only a reduction in recurrent ischemia o The dutch situation differs from most other european countries in that nearly all dutch hospitals have CCU/EHH wards and heart catheterization laboratories o Experience learns that calamities during medical stabilization of NSTEMI-ACS are rare o Implementation of the guidelines would lead to major logistical and economical consequences for both PCI and non PCI centers, without overt health care benefit

14 Meta analysis NSTEMI-ACS trials Mortality New MI Milasinovic e.a. atheroslerosis 2015

15 Meta analysis NSTEMI-ACS trials Recurrent ischemia Milasinovic e.a. atheroslerosis 2015

16 Subgroup analysis ELISA 3 study Relative Risk of primary and secondary endpoints at 30 d follow-up in patients randomized to early or late intervention in PCI versus non-pci centers Badings e.a. NeHJ 2016

17 Subgroup analysis ELISA 3 study Timing of procedures in PCI versus non-pci centers for patients randomized to early or late intervention Badings e.a. NeHJ 2016

18 All high risk NSTEMI-ACS to an intervention center Consequences for non intervention centers Approximately 50% reduction of coronary angiograms o Adherence to volume criteria o Experience o Closure of many cath. labs Decline in presentation of chest pain patients on EHH/CCU o Differentiation of risk at FMC o Differentation with type 2 infarction or non coronary emergency o Potential transfer of most or all chest pain patients to intervention centers o Threat on continued existence of many CCU wards Potential loss of knowledge and experience Major economical consequences for the hospitals

19 All high risk NSTEMI-ACS to an intervention center Consequences for intervention centers Strong increase in patient numbers o Huge regional coronary care centers Major impact on infrastructure and logistics Major impact on staffing Major investments needed

20 Pros and cons of restricting coronary angiography to intervention centers Pro Adherence to ESC guidelines concerning NSTEMI-ACS patients Less recurrent ischemia and shortening of length of hospital stay for NSTEMI-ACS patients waiting for intervention o But by improving current regional working protocols no longer relevant Less need for repeated catheterization o FFR/IVUS/OCT procedures can be done in the same setting o Ad hoc PCI might be considered (with/without ad hoc heart team decision) o Even in NSTEMI-ACS only 40% of patients eventually need a second (interventional) procedure Higher procedural succes rate and better image quality o If at all, only in the hands of experienced operators Probably less interhospital transfers o Provided patients are directly discharged from PCI centers and wait for CABG in surgical centers

21 Pros and cons of restricting coronary angiography to intervention centers Cons No overt health care benefit, if at all Major logistical consequences o Infrastructure PCI centers (hospital beds, cath. labs) o Staffing (interventional cardiologists, cath. lab personnel) o Ambulance services Increase in transfer of ACS patients to PCI centers and potentially all chest pain patients Potential increase in interhospital transfers o Waiting times Waste of investments and human resources in non PCI centers

22 Pros and cons of restricting coronary angiography to intervention centers Cons More exchange of medical information, potentially leading to more mistakes Threat on continued existence of CCU/EHH wards in non intervention centers Potential closure of most non interventional cath. labs Potential loss of experience and knowledge concerning ACS in non PCI centers Most likely not in line with patients preference Coronary angiography during training will have to be restricted to fellows interventional cardiology I supect it will be much more costly

23 Based on today s situation Is there a future? Yes

24 Based on today s situation Is there a future? Yes but we can do better

25 Improving today s situation Improve quality and succes of diagnostic procedures o A minimum of 75 procedures a year per operator o Radial approach encouraged o Sub specialization in each center Improve logistics in high risk NSTEMI-ACS patients o Coronary angiography within 24 hours, same day heart team decision o Percutaneous interventional procedure, if indicated, on the day after heart team decision Adequate regional working protocols Projectgroup ACS from NVVC o Investigate current practice in NSTEMI care More research

26 What s on the horizon? Famous study o Point of care troponin assay in the ambulance, HEART score at presentation Selecting very low risk patients to keep them out of the hospital Identifying a highest risk subset within the NSTEMI-ACS subgroup that may potentially profit from direct transfer to a PCI center CT-FFR

27 CT-FFR Hwang et al, Korean J Radiol. 2016

28 Future directions