Elsevier

American Heart Journal

Volume 139, Issue 1, January 2000, Pages 106-113
American Heart Journal

Effect of variability in the interpretation of coronary angiograms on the appropriateness of use of coronary revascularization procedures,☆☆,

https://doi.org/10.1016/S0002-8703(00)90316-8Get rights and content

Abstract

Background Evidence from numerous studies of coronary angiography show differences between observers’ assessments of 15% to 45%. The implication of this variation is serious: If readings are erroneous, some patients will undergo revascularization procedures unnecessarily and others will be denied an essential treatment. We evaluated the variation in interpretation of angiograms and its potential effect on appropriateness of use of revascularization procedures. Methods and Results Angiograms of 308 randomly selected patients previously studied for appropriateness of angiography, coronary artery bypass grafting (CABG), and percutaneous transluminal coronary angioplasty (PTCA) were interpreted by a blinded panel of 3 experienced angiographers and compared with the original interpretations. The potential effect on differences on the appropriateness of revascularization was assessed by use of the RAND criteria. Technical deficiencies were found in 52% of cases. Panel readings tended to show less significant disease (none in 16% of vessels previously read as showing significant disease), less severity of stenosis (43% lower, 6% higher), and lower extent of disease (23% less, 6% more). The classification of CABG changed from necessary/appropriate to uncertain/inappropriate for 17% to 33% of cases when individual ratings were replaced by panel readings. Conclusions The general level of technical quality of coronary angiography is unsatisfactory. Variation in the interpretation of angiograms was substantial in all measures and tended to be higher in individual than in panel readings. The effect was to lead to a potential overestimation of appropriateness of use of CABG by 17% and of PTCA by 10%. These findings indicate the need for increased attention to the technical quality of studies and an independent second reading for angiograms before recommending revascularization. (Am Heart J 2000;139:106-13.)

Section snippets

Sample

We selected 3 samples of angiograms for review from our previously reported study of the appropriateness of coronary angiography, CABG, and PTCA in 1990 in nonfederal hospitals in New York State.

To evaluate variation in assessing the extent of disease, we sampled angiograms from the study of appropriateness of angiography.13 For that study, patients were selected by a 2-step sampling process. Hospitals were randomly sampled from several strata: geographic location, number of angiographies

Adequacy of angiograms

Although in most cases it was possible for Duke angiographers to visually interpret lesions despite technical deficiencies, in 7 cases the technical quality of the study was so poor that adequate visual assessment of the lesions was impossible. In another 5 cases, major epicardial vessels were not injected. These cases were excluded. In 1 previous angiography case, clinical data were inadequate to permit classification for appropriateness of revascularization; therefore it was also excluded,

Discussion

Cardiologists have wrestled with the problem of reproducibility of visual angiographic interpretation of lesion severity for more than 2 decades. The lack of agreement between readers has been disturbingly high as well as remarkably consistent. In 1975, Detre et al6 reported the results of a study in which 22 physicians interpreted 13 angiograms on 2 separate occasions. They found interobserver agreement on extent of disease to be approximately halfway between 100% and chance, and intraobserver

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    Guest Editor for this manuscript was Blase A. Carabello, MD, Medical University of South Carolina, Charleston.

    ☆☆

    Reprint requests: Lucian L. Leape, MD, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115.

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