Stents not effective? Study sparks debate pt. 1

U.K. PCI study sparks U.S. debate

On Wednesday, November 1, results from the Objective Randomized Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) study were published in The Lancet.

The next day, this article was published in the New York Times:

"A procedure used to relieve chest pain in hundreds of thousands of heart patients each year is useless for many of them," it began... "The new study, published in the Lancet, stunned leading cardiologists by countering decades of clinical experience. The findings raise questions about whether stents should be used so often—or at all—to treat chest pain."

Without further knowledge, the debate may start right here—the New York Times article had little in the way of medical detail to satisfy invasive cardiovascular professionals and may have further generalized results in a misleading manner.

But let's hold off on reacting, look at the debate surrounding this particular study and also place the findings in a wider context (part two). Note: this isn't the first time it has been suggested that stents are overused.

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One Minute, Shared Decision-Making Aid Reduces Unnecessary Hospitalization

Additional cardiac imaging often unnecessary

Last week, Mayo Clinic researchers showed that using a shared decision-making aid to involve more patients in care decisions can prevent both unnecessary hospitalization and more advanced cardiac tests for patients with low-risk chest pain.

The "Chest Pain Choice" shared decision-making aid is one of the latest evidence-based practices built on high-sensitivity troponin rule-out of acute coronary syndrome for ED patients reporting acute chest pain. After the one-hour test, an additional "one minute" discussion to educate patients about their risk and reach a shared decision can prevent further unnecessary and costly testing.

ACVP Blog has discussed decision-making for acute chest pain before, suggesting that the fact the cardiac biomarker test can safely and accurately rule-out acute coronary syndrome within one hour "challenges [the] need" for commonly-used noninvasive imaging prior to patient discharge.

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A new cardiac imaging paradigm for acute chest pain?

In the "high-sensitivity cardiac troponin era," will the role of cardiac imaging in the ED change?

As high-sensitivity cardiac troponin (hs-cTn) assays become more and more common, cardiac imaging becomes less necessary for ruling out acute myocardial infarction (AMI) in ED patients with acute chest pain, but might be useful to prevent unnecessary or aggressive treatments write experts in July's volume of the American Heart Journal.

ACVP blog has covered the groundbreaking research on the high-sensitivity cardiac troponin tests since early last year, when we reported a new strategy that could rule out acute myocardial infarction within one hour, and rule it in with 75 percent accuracy. In June, two studies publishes in JAMA Cardiology lent further support to one-hour algorithms.

The speed and safe, accurate "rule out" of acute myocardial infarction through these cardiac biomarker tests "challenges [the] need" for noninvasive imaging prior to patient discharge when troponin values are normal, write the authors of the American Heart Journal article.

Continue reading A new cardiac imaging paradigm for acute chest pain?