Percutaneous transluminal coronary angioplasty - update of applications and standards for utilization - nonsystematic review
Conseil d'Evaluation des Technologies de la Sante du Quebec
Record ID 31998008420
Ischemic heart disease, of which myocardial infarction, stable and unstable angina are the principal manifestations, remains the leading cause of mortality and morbidity in western societies, including Quebec. Percutaneous transluminal coronary angioplasty (PTCA) has become a standard therapeutic modality for the treatment of coronary artery disease. Technological improvements have ameliorated its safety profile and its indications are widening. This report updates a previous report from CETS on standards of utilization and also examines newer applications of this technology.
Authors' results and conclusions:
Before the introduction of PTCA, catheterizations were often performed only if surgery was contemplated. Angioplasty by providing a valid treatment option which may positively influence quality of life has consequently increased diagnostic cardiac catheterizations. Practice patterns have also evolved with increased interventions following an acute coronary event and from greater applications to the elderly.
Primary PTCA may improve survival in highly selected patients with acute myocardial infarction but thrombolysis should remain the predominant treatment option. At present primary PTCA is indicated only in patients ineligible for thrombolysis or those with at very high risk with conventional thrombolysis and who can be treated within 30 to 60 minutes in very high quality catheterization laboratories. The desire to occasionally perform primary PTCA is not a sufficient reason to expand angioplasty facilities.
Routine PTCA following an acute ischemic event has not been shown to improve patient outcomes. These patients should consequently be stratified to identify those at high risk where the greatest possible benefit is to be expected.
While the safety profile of angioplasty has improved considerably over the past ten years, it is nevertheless recommended, as in the earlier Conseil report, that angioplasty continue to be restricted to centres with on-site cardiac surgery in order to offer the safest conditions. Further, it is to be expected that the optimal decision for many patients involves the close collaboration of both cardiac surgeons and interventional cardiologists.
The Conseil recognises that other policy arguments, including access to care and economic issues, may influence the decision to permit PTCA in centres without on-site surgery and therefore offers the following guidelines. If a centre without on-site surgical backup does perform angioplasty it is essential that only well defined low risk patients be accepted and that a formal feasible transfer policy be operational. The delay for urgent cardiac surgery following a PTCA complication should not be prolonged over what is experienced by patients undergoing PTCA in hospitals with on site surgery. Operators should be well skilled in the use of coronary stenting to treat acute angioplasty complications. Further, minimal yearly critical caseloads, approximately 250 and 100 cases per institution and individual operator respectively, are necessary to ensure optimal performance. Finally, periodic reviews of the results are necessary to assure adequate quality control.
English language abstract:
An English language summary is available
- Angina Pectoris
- Coronary Disease
- Myocardial Infarction
Conseil d'Evaluation des Technologies de la Santé du Québec
Conseil d'Evaluation des Technologies de la Santé du Québec, 2021, avenue Union, #1040, Montréal, Québec H3A S29, Canada. Tel: 514-873-2563; FAX: 514-873-1369
Conseil d'Evaluation des Technologies de la Sante du Quebec (CETS)