Many Non-Emergency Angioplasties May Be Unnecessary

July 5, 2011 -- The vast majority of angioplasties performed in emergency situations in the U.S. are appropriate, but as many as half of those conducted in non-emergency situations may not benefit patients, a new study suggests.

About one in nine elective angioplasty procedures performed in patients with few or no symptoms were considered inappropriate by researchers, with substantial variability from hospital to hospital, according to the study.

The study is published in the July 6 issue of TheJournal of the American Medical Association.

Emergency vs. Non-Emergency Angioplasties

About 600,000 angioplasties with or without stenting to open blocked arteries are performed in the U.S. each year at a cost of more than $12 billion.

The analysis of just over half a million procedures conducted between July 2009 and September 2010 assessed their appropriateness or inappropriateness based on criteria developed by the American College of Cardiology, the American Heart Association, and other health groups.

The procedures were performed at close to 1,100 hospitals across the U.S.

More than two out of three angioplasties (71%) were done in acute, or emergency situations, such as a heart attack or unstable angina. Almost all of these procedures (98%) were judged appropriate.

But of the close to 145,000 non-emergency procedures conducted in patients, many with few symptoms or no symptoms at all, almost 55,000 (38%) were judged questionable and 11% were found to be inappropriate.

Most of these interventions were done in patients without angina or in patients whose diagnostic stress tests indicated that they were at low risk for significant heart disease.

"About one in nine angioplasties in the non-acute setting were unlikely to benefit the patient," says lead researcher Paul S. Chan, MD, of Saint Luke's Mid America Heart and Vascular Institute in Kansas City, Missouri.  "More than half of these patients had no symptoms and most of the others had very mild symptoms."

Recent studies suggest that angioplasty conveys little benefit over other treatments in patients with stable heart disease or in patients with no symptoms such as heart pain or shortness of breath, Chan says.

"The benefit in the elective setting is really symptom relief," he tells WebMD. "We now know that in this setting angioplasty doesn't appear to extend life, so in the absence of symptoms there may be little reason to do it."

Comparing Hospitals

Private and public hospitals had similar rates of inappropriate angioplasty procedures.

About a quarter of hospitals providing data had inappropriate procedure rates in non-emergency situations of 6% or less. Another quarter had rates of 16% or more. At a small minority of hospitals, 40% or more of the non-emergency angioplasties were judged to be inappropriate.

"Overall, this report is good news, but it is clear that there is room for improvement on a hospital-by-hospital basis," says cardiologist David Faxon, MD, of Boston's Brigham and Women's Hospital.

Faxon, who is a former president of the American Heart Association, tells WebMD that the study may underestimate the actual number of inappropriate angioplasties in non-emergency settings because the data were provided by the hospitals, with no independent oversight.

The American College of Cardiology plans to provide quarterly report cards to the hospitals participating in the angioplasty registry.

American College of Cardiology President David Holmes, MD, says the reports will help individual hospitals access their own performance in comparison to other hospitals.