Category Archives: Appropriate Use Criteria (AUC)

COURAGE: Does 15-Year Data Have Any Clinical Relevance?

pills_vs_stent_140sqThis past week saw publication of an update to the 2007 COURAGE trial which compared optimal medical therapy (OMT) to stenting (PCI) as the initial management strategy for stable coronary artery disease. (Please note the phrase “initial management strategy.” This will not be the last time you see it in this post.)

Appearing in the New England Journal of Medicine and titled “Effect of PCI on Long-Term Survival in Patients with Stable Ischemic Heart Disease,” this study, performed by Dr. Steven P. Sedlis and other COURAGE trial investigators, is described as “an extended survival analysis to examine the potential long-term survival benefit from initial PCI among the patients with stable ischemic heart disease who were followed for up to 15 years after initial enrollment in the COURAGE trial.”

This new analysis concluded: “…we did not find a difference in survival between an initial strategy of PCI plus medical therapy and medical therapy alone in patients with stable ischemic heart disease.” This also was the finding of the original COURAGE trial at five years. Continue reading

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Filed under Appropriate Use Criteria (AUC), Bare Metal Stents, Clinical Trials / Studies, COURAGE, Drug-Eluting Stents, FAME I / FAME II, FFR, Intravascular Guidance, IVUS, OCT, Optimal Medical Therapy, Stent

Fractional Flow Reserve and Ebola: Thresholds and Decision-Making

   This week started off with me watching a demonstration of fractional flow reserve (FFR) during multivessel PCI. This very instructive case was transmitted live from Hammersmith Hospital in London and featured Dr. Justin E. Davies showing how to perform FFR and, more importantly, how the use of FFR changed the treatment plan for this patient.

The angiogram had shown three intermediate blockages (LAD, OM, RCA) and, as such, this patient might have been a candidate for CABG instead of PCI. However, when FFR was used to measure whether or not these blockages were ischemic, two were found to be hemodynamically insignificant: it would be safe to defer stenting and treat them medically. The third lesion in the LAD clearly was the cause of the symptoms and stenting would have benefit for the patient. Continue reading

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Filed under Appropriate Use Criteria (AUC), FAME I / FAME II, FFR, Media Coverage, Stent, Video

Will a Denial of Service DOS Attack Hit New York State Medicaid Patients? Or Perhaps Your State?

  What does a Denial of Service Attack have to do with stents, angioplasty and PCI?

In the world of computing, a DOS attack is defined as “an attempt to make a machine or network resource unavailable to its intended users.” Typically netbots programmed by hackers overwhelm the web servers of banks, credit card providers, etc. whose sites then become unavailable to their customers. Now it seems similarly that in New York State, cardiovascular treatments may become unavailable to some Medicaid patients: a denial of service. Continue reading

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Filed under ACC, Appropriate Use Criteria (AUC), Cost Effectiveness, Health Insurance, Interviews, Media Coverage, SCAI

Ask George W. Bush a Question About His Stent…or Anything Else

Ask Bush a QuestionWant to ask George W. Bush a question about his stent…or anything else? Click here!

Six months ago, former President Bush received an angioplasty and stent. The stent was recommended by Bush’s doctors to open a blockage in one of his coronary arteries, found during his annual physical exam. EKG changes were seen on his stress test, a CT angiogram was performed and a blockage seen. He was rushed off to Texas Health Presbyterian Hospital in Dallas where Dr. Tony Das performed a percutaneous coronary intervention (PCI, a.k.a. angioplasty). A single stent was inserted in the newly opened vessel. Continue reading

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Filed under Appropriate Use Criteria (AUC), Celebrity Patients, Media Coverage, Meetings & Conferences, Stent

George W. Bush Gets Angioplasty and Stent – Was It Necessary?

George W BushFormer President George W. Bush received an angioplasty and stent this morning at Texas Health Presbyterian Hospital Dallas. The stent was recommended by Bush’s doctors to open a blockage in one of his coronary arteries, found yesterday during what was described by Bush spokesman Freddy Ford as his annual physical exam at the Cooper Clinic in Dallas. Continue reading


Filed under Angiograms, Appropriate Use Criteria (AUC), Cardiac CT, Celebrity Patients, COURAGE, Drug-Eluting Stents, FFR, Imaging, Media Coverage, Non-Invasive Testing, Optimal Medical Therapy, Stent

USA Today Claims Stents and Angioplasty “Often Unnecessary”

Coronary StentYesterday’s edition of USA Today carried an article by Peter Eisler titled, “Six common surgeries often done unnecessarily” — and, you guessed it, angioplasty and stents were at the top of the list of “six common surgeries that carry significant risks of being done without medical necessity, according to federal data and independent studies.”

I was a bit taken aback because I was not aware of any new study, federal or independent, that concluded stents were being vastly over-used. And it turns out that there wasn’t one. Continue reading

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Filed under Appropriate Use Criteria (AUC), Clinical Trials / Studies, COURAGE, FAME I / FAME II, Heart Attack, Media Coverage, Shared Decision-Making, Stent

Stents, Trials and Studies: What’s in a Word?

What's In a Word?Today the editors of the HEART Group Journals, comprising the Journal of the American College of Cardiology and other participating cardiovascular publications, issued a “Statement on Matching Language to the Type of Evidence Used in Describing Outcomes Data.”

Although the title of the article may be a bit yawn-inducing, the editors deserve a kudo or two for attempting to clarify reporting on medical issues. Continue reading

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Filed under ACC, Appropriate Use Criteria (AUC), Clinical Trials / Studies, Drug-Eluting Stents, FDA, Media Coverage, Patients