If the address matches an existing account you will receive an email with instructions to retrieve your username. Clinical Cardiology Volume 10, Issue Book Reviews Open Access. Joseph Lindsay Jr. Washington, D.
State of the art: coronary angiography.
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State of the Art in Quantitative Coronary Arteriography | SpringerLink
Close Figure Viewer. Browse All Figures Return to Figure. The study sample included patients who underwent PCI of lesions by physicians at 35 hospitals in 18 provinces of China. Among patients without AMI, A total of 31 4. Among patients with AMI, There was no significant difference in accuracy according to the vessel.
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In non-AMI patients, the difference was greater with shorter lesions and larger reference vessel diameters, but this pattern was not seen among patients with AMI Table 2. When the analyses were conducted using only results from each of the QCA laboratories, respectively, the results were qualitatively similar eTable 3 in the Supplement. In patients with AMI, the overall mean difference among all 29 hospitals was In non-AMI patients, the overall mean difference among all 57 physicians was In AMI patients, the overall mean difference among all 48 physicians was In a large population of patients and lesions treated with PCI in China, we found that PVA resulted in more severe stenosis determinations than those calculated using a core laboratory-derived QCA.
These angiographic studies, which encompass a diverse group of procedures at these hospitals, rarely included FFR to assess functional severity of anatomical lesions. This study extends the existing literature in several important ways. First, to our knowledge it is the largest study to date to evaluate the interpretation of percent diameter coronary stenosis by PVA and QCA.
It also demonstrates that the concerns raised in previous US-based studies also apply to China, where half a million PCIs are performed each year. Finally, owing to its large sample size, this study is the first to examine the variation between PVA- and QCA-defined stenosis severity across hospitals and physicians. In China, the volume of PCI procedures performed has increased markedly in the past decade, accompanied by a rapid increase in the number of PCI-capable hospitals and interventional cardiologists.
Although panel readings have been shown to improve the accuracy of angiogram interpretation, 18 , 19 the proportion of ad hoc PCIs in China has increased rapidly, 13 thereby expanding the influence of inaccurate interpretations by individuals. Incorporating the accuracy of stenosis severity into quality assurance systems at the hospital and physician level may help to increase the accuracy of visual interpretation and minimize variations.
The study has several important implications. The assumption of accurate and reproducible assessment of coronary stenosis severity serves as the foundation for current clinical decisions regarding revascularization. Despite being challenged as long as 40 years ago, 7 , 20 owing to its convenience, efficiency, and ease of implementation, visual assessment is still the main method used to determine percent diameter stenosis in China and other countries. Given that the clinical standard, PVA, frequently resulted in an overestimate of lesion severity compared with the less subjective QCA, it is possible that revascularization would not have been pursued in some lesions—an implication that is similar to findings from the United States.
Our findings are particularly important in China, where functional assessments are rarely used and decisions about interventions rely heavily on PVA.
Yet, this phenomenon is not unique to China; for example, in the US Medicare population, only Also, many patients, despite national insurance, may have considerable out-of-pocket costs associated with these procedures, highlighting the need for prudent use of the procedures. For our study, we employed methods similar to those used in a study in the United States 9 to permit a comparison of findings.
Quantitative coronary angiography has been widely used for decades in clinical research and, in selected cases, in clinical practice, owing to its reproducibility and validity. However, our findings remained robust when we excluded complex lesions.
Furthermore, based on the Appropriate Use Criteria, angiographic determination of stenosis severity remains a cornerstone in revascularization decisions. There are potential remedies to the limitations of QCA. There is evidence that group reading can improve the accuracy of interpretations.
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Moreover, there may be ways to easily incorporate some of the principles of QCA into real-time practice, such as a standardized calibration process using specific catheters. Also, feedback to practitioners, enabling calibration of their interpretations, might be useful—as might be computerized training programs. In addition, the development of machine-learning techniques 22 may provide tools to help physicians interpret coronary stenosis more accurately.
Finally, FFR may be estimated with techniques such as computational fluid dynamics. Certain limitations should be considered in the interpretation of this study. First, hospitals participating in the study represented a select group of tertiary care facilities, so we may have underestimated the magnitude of misinterpretation had less sophisticated hospitals been included.
Second, owing to the small number of physicians in each hospital, we were unable to assess the between-physician variation in a hospital. Third, this is a pragmatic study of actual practice and we do not have details on how they produced their estimates of lesion severity.
Finally, we did not evaluate cases where PCI was not performed and were unable to assess when angiographically severe stenoses were underappreciated. In this large study of patients undergoing contemporary PCI in China, we found that PVA significantly overestimated coronary stenosis severity compared with independent measurements by QCA, supporting the need for greater use of functional assessments prior to the performance of PCI.
Large variations across hospitals and among physicians suggest that efforts are urgently needed to improve the accuracy of interpretations of coronary angiograms and to optimize the selection of patients for PCI in current clinical practice. Published Online: January 16, Author Contributions: Dr Jiang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Drs Zhang and Mu contributed equally to the study. Drs Krumholz and Jiang contributed equally to the study and are joint senior authors. Li, X. Li, Zheng, Y. Li, Krumholz. Li, Zheng, Krumholz, Jiang.
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Li, Zheng. Cohen receives research grant support from Medtronic, Boston Scientific, and Abbott Vascular, and consulting fees from Medtronic. No other disclosures are reported. Chan School of Public Health. We are grateful for the support provided by the Chinese government. All Rights Reserved. Figure 1. View Large Download. Table 1. Between-laboratory comparison of quantitative coronary angiography eTable 2. J Am Coll Cardiol. PubMed Google Scholar Crossref. Putting ad hoc PCI on pause. Effect of variability in the interpretation of coronary angiograms on the appropriateness of use of coronary revascularization procedures.
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