Coronary Intervention
Process of Care Assessment in Patients With Chronic Total Occlusion
2022 Volume 86 Issue 5 Pages 808-810
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2022 Volume 86 Issue 5 Pages 808-810
Percutaneous coronary intervention for lesions with chronic total occlusion (CTO-PCI) remains technically challenging. Among patients who undergo coronary angiography, the incidence of CTO has been reported to be as high as 15–30%.1 As with any patient with stable coronary artery disease (CAD), standard treatment for CTO patients should include antianginal therapy. Typically, patients who remain symptomatic or have a large burden of ischemia despite maximal medical therapy would be considered for revascularization. In most circumstances, coronary artery bypass grafting is considered too invasive; consequently, most CTO patients are referred for PCI.
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In order to facilitate appropriate patient selection for PCI in general, appropriate use criteria (AUC) for coronary revascularization have been endorsed by 6 professional societies in the USA in 2009, and revised in 2012 and 20172–4 (Figure 1). The appropriateness rating for each clinical scenario is determined on the basis of the different combinations of the clinical items (Figure 2). In the USA, appropriateness assessment demonstrated that 11.6% of PCIs were deemed to be inappropriate in non-acute settings (by 2009 AUC), and 26.2% when using the revised 2012 AUC.5,6 Directionally similar finding were found in a Japanese multicenter PCI registry.7,8
Time line of major publications related to appropriate use criteria (AUC) for stable ischemic heart disease (SIHD). ACC/AHA, American College of Cardiology/American Heart Association; COURAGE, Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation; CTO-PCI, percutaneous coronary intervention for lesions with chronic total occlusion; ISCHEMIA, International Study of Comparative Health Effectiveness with Medical and Invasive Approaches; JCS, Japanese Circulation Society; KiCS-PCI, Japan Cardiovascular Database – Keio interhospital Cardiovascular Studies; PCI, percutaneous coronary intervention.
Methodology for the development of appropriate use criteria. The purpose of this procedure is to reduce the variety of responses among the panelists and obtain the most reliable conclusions.
In large-scale randomized clinical trials conducted in stable CAD patients, PCI has demonstrated only modest outcome benefit.9 Hence, the indication of CTO-PCI requires in-depth discussion. In this issue of the Journal, Seki, et al evaluate the appropriateness of CTO-PCI in Japan using the Japanese CTO-PCI Expert Registry under the updated 2017 AUC.10 There are 3 main findings: (1) roughly 50% of patients were asymptomatic, (2) about 15% of CTO-PCIs were rated as “rarely appropriate”, and (3) the rate of “rarely appropriate” CTO-PCIs varied substantially among operators ranging from 3% to 25% without any association of their ratings and procedure volumes. Notably, 22.4% of patients were not on any antianginal drugs, with half of the patients not receiving β-blockers (recommended as first-line drugs for treating angina in clinical practice guidelines).11 In patients who do not tolerate or adequately respond to β-blockers, calcium-channel blockers and/or long-acting nitrates are recommended as alternatives. Recent landmark randomized controlled trials indicate little incremental survival benefit of PCI in stable CAD patients treated with optimal medical therapy, regardless of ischemic burden or anatomy, and CTO lesions are no exceptions.12,13
Technically, owing to updates of the mapping algorithm in AUC 2017, direct comparison of appropriateness with previous studies evaluated under the older version of AUCs needs cautious interpretation. The most important update in relation to the Seki et al’s work is that “chronic total occlusion” is no longer treated as a specific clinical scenario in AUC 2017, whereas, in the older versions of AUCs, there were several clinical scenarios that focused on CTO-PCI.4,5 Despite this major update, the rate of “rarely appropriate” indications (≈15%) was comparative to prior reports, and the typical clinical scenario deemed as “rarely appropriate” was also consistent.8 These findings suggest that typical “rarely appropriate” clinical scenarios are universal issues regardless of the AUC updates, and the indication of CTO-PCI should be more carefully assessed given its relatively higher risk.
The success rate of CTO-PCI has substantially improved over time. Despite this, we should keep in mind that our goal is not to focus on the ‘blocked coronary arteries’, but to improve anginal symptoms and clinical outcomes in patients with stable ischemic heart disease. In addition to AUC, scoring tools that predict long-term adverse cardiac events14 or ‘survival advantage’15 after successful CTO procedures can also be a valid instrument for clinical decision-making. Careful patient selection and optimizing medical therapy prior to the procedure remain the key components in managing CTO patients.
None for the manuscript.
S.K. received an unrestricted research grant for the Department of Cardiology at Keio University School of Medicine from Daiichi Sankyo and Novartis; and received lecture fees from AstraZeneca and Bristol-Myers Squibb. T.I. has no disclosures to report.
