The use of functional tests and planned coronary angiography after percutaneous coronary revascularization in clinical practice.Results from the AFTER multicenter study
Introduction
The follow-up strategies after percutaneous coronary intervention (PCI) have relevant economic implications, may influence the patient's subsequent management and the need of further invasive procedures [1], [2], [3], [4]. Despite that, the subgroups of patients that could take advantage from the use of functional testing (FT) or coronary angiography (CA) after PCI are not well defined. The type, number and timing of FT that should be performed are not established, as well as the discontinuation of medical treatment during tests and the duration of the follow-up program.
No specific guidelines and recommendations are provided by the European Society of Cardiology. The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for PCI [5] and for cardiac radionuclide imaging [6] refer to the ACC/AHA guidelines for exercise testing [7]. The use of FT after PCI is clearly indicated (Class I) only in those patients with recurrent symptoms. It is controversial (Class II B) in selected high-risk asymptomatic patients which include patients with diabetes mellitus, multivessel disease, proximal left anterior descending coronary artery PCI, left ventricular dysfunction and suboptimal PCI result. It is not indicated (Class III) as routine strategy in asymptomatic patients. ACC/AHA guidelines for PCI [5] suggest that planned CA should be considered only in the setting of left main coronary artery PCI (Class II A). Such recommendations are supported by limited clinical evidences and result from consensus rather than prospective randomized or observational data.
Little is known about the use of FT and angiographic follow-up in the “real world”. Major variations are observed, and the clinical and procedural risk profile of the patients do not seem to play a significant role in the choice of the follow-up strategy [8], [9].
The Angioplasty Follow-up: Tests and Events Registry (AFTER) is a prospective multicenter registry that was conceived with the aim of describing the type, number and timing of FT after PCI, clinical and procedural profile of tested and non-tested patients, and the subsequent rate of further invasive procedures and clinical events.
The primary objectives of the current report are to evaluate the effect of clinical, procedural and organizational variables on the execution of FT or planned CA after PCI, and to assess the impact of ACC/AHA guidelines recommendations for the use of follow-up tests on clinical practice.
Section snippets
Methods
The Italian region of Lazio has 5.1 million inhabitants and is one of the most populated regions of Italy. In 2004 the area was serviced by 21 catheterization laboratories that performed a total of 8428 PCIs (official data of the Italian Society of Interventional Cardiology—www.gise.it). Twelve of those centers were involved in the AFTER study (see Appendix A). Patients undergoing PCI between November 15 and December 15 2004 were consecutively enrolled before the procedure and were followed-up
Results
A total of 473 patients were enrolled. Eight patients (1.7%) died during hospitalization and 45 patients were lost during follow-up. Therefore data from 420 patients (90%) were available for analysis.
During the 12-month follow-up a total of 425 FT and 39 planned CA were performed. Two hundred seventy-nine patients (66%) underwent at least one FT, and 33 of them underwent also one or more planned CA. Among patients who did not undergo any FT, CA was performed in 4 (1%) as a scheduled alternative
Discussion
This multicenter study prospectively investigates the use of non-invasive testing and coronary angiography after PCI in a large cohort of consecutive patients enrolled in a short time in a representative region of an European country. We found that the use of FT and planned CA after PCI is unrelated to patient's symptoms, is not influenced by ACC/AHA guidelines and is not tailored to the risk period for restenosis.
Conclusions
The use of functional and invasive testing after PCI in the “real world” is unrelated to clinical and procedural characteristics of the patients, and depends on patient's age and logistics, such as the different standards of the clinical centers performing PCI and the reference center for follow-up. The timing of post-PCI FT and planned CA varies widely, and is not tailored to the risk period for restenosis. ACC/AHA guidelines, that favor a selective use of testing according to the occurrence
Acknowledgement
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [24].
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