NEW ORLEANS — Most individuals undergoing elective percutaneous coronary intervention have highly unrealistic expectations about the procedure's benefits, according to a patient survey.
Two-thirds of survey respondents believed their elective percutaneous coronary intervention (PCI) would extend their life span. An even larger percentage thought it would reduce their chances of having an MI. Neither belief is valid, of course, Dr. John Lee noted at the annual scientific sessions of the American Heart Association.
Moreover, only 31% of those surveyed thought their procedure was done to reduce their anginal symptoms, which is the one evidence-based reason for performing elective PCI, added Dr. Lee of the Mid-America Heart Institute, Kansas City, Mo. “The implication of this study is that better patient communication is needed prior to elective PCI to convey the evidence-based risks and benefits and elicit a more truly informed consent,” he said.
Dr. Lee sent his brief single-page questionnaire survey to 498 consecutive patients who underwent elective PCI at two Kansas City hospitals between January 2006 and October 2007; 350 patients responded.
Surprisingly, one-third of the patients were under the mistaken impression that their PCI had been done on an emergency basis (see box). Sixty-eight percent indicated that no treatment option other than PCI was discussed with them. Eighteen percent said they were offered medical management, and 13% recalled coronary artery bypass graft surgery being discussed.
Dr. Lee observed that his survey results were quite similar to those of an 8-year-old survey led by Dr. Eric S. Holmboe, a general internist who today serves as senior vice president for quality research and academic affairs at the American Board of Internal Medicine in Philadelphia. Three-quarters of respondents to Dr. Holmboe's survey believed their elective PCI would prevent a future MI, and 71% thought it would prolong their life (J. Gen. Intern. Med. Sept. 2000; 15:632–7).
Since that survey, however, considerable additional evidence has accrued as to what elective PCI can and cannot accomplish. A meta-analysis of 11 randomized trials comparing it with conservative management in patients with chronic stable coronary artery disease showed no advantage for elective PCI in terms of death, MI, or need for repeat revascularization (Circulation 2005;111:2906–12).
This meta-analysis was followed by the widely publicized 2,287-patient randomized Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, which showed no difference between elective PCI and medical management in rates of death, MI, stroke, or hospitalization for acute coronary syndrome (N. Engl. J. Med. 2007; 356:1503–16).
COURAGE was published while Dr. Lee was conducting his survey. He found no significant difference between patient responses obtained preversus post-COURAGE.
“It's not surprising that we'd see no differences in patient perceptions of benefit, because most patients don't read the medical literature. But the lack of a difference in the treatments being offered post-COURAGE was a little more surprising,” he commented.
One audience member asked whether the disturbing survey results reflect wishful thinking on the patients' part or if physicians are misinforming them.
“Patients really go down a line of physicians before they end up in the cath lab,” Dr. Lee replied. “They start off with their primary care doctor, who suspects [coronary artery disease] and sends them off to get a stress test. Then they may go to the interventionalist's office for a consultation, then to the cath lab. There are many steps along the line where they can get their information. It's probably the responsibility of every single one of those physicians to educate the patient.”
Surprisingly, 68% of patients said that no treatment option other than PCI was discussed with them. DR. LEE
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