‘Misalignment’ Exists Between What Concerns Patients and Physicians Most After PCI

Approximately one in five patients undergoing coronary angiography considers avoiding the drawbacks of dual antiplatelet therapy (DAPT) to be the single most important factor when selecting a stent, new research shows.

In contrast, the desire to avoid repeat revascularization is the key consideration when selecting a stent for just 14.4% of patients undergoing angiography, while two-thirds place equal emphasis on avoiding future revascularizations and the drawbacks of DAPT.

Overall, 85% of the patients surveyed who went on to PCI received a drug-eluting stent, with investigators reporting no difference in DES use among patients who valued avoiding DAPT drawbacks, those who valued avoiding a repeat procedure, and those who placed equal emphasis on both considerations.

The results, which were published online February 7, 2017, in Catheterization and Cardiovascular Interventions, suggest that physicians are “prioritizing the avoidance of repeat revascularization procedures” instead of engaging patients in the shared decision-making process recommended by several organizations, including the American Medical Association and Institute of Medicine.

We feel that these kinds of decisions are made because the physicians have a strong bias toward the drug-eluting stent technology.  Adnan Chhatriwalla

Senior investigator Adnan Chhatriwalla, MD (St. Luke’s Mid America Heart Institute, Kansas City, MO), emphasized that they only surveyed patients prior to coronary angiography and this information was not used in the decision-making process when physicians selected either a bare-metal or drug-eluting stent in PCI cases.

The data, however, do suggest there is a “misalignment” between what patients’ value most and what interventional cardiologists prioritize when selecting treatment, said Chhatriwalla. 

Physicians Biased Toward Drug-Eluting Stents

In the United States, more than 80% of PCI procedures are performed with a drug-eluting stent. Speaking with TCTMD, Chhatriwalla said that this percentage appears to be even higher among cases done by interventional cardiology leaders. When he participates in panel discussions at major medical meetings, many interventionalists claim to use drug-eluting stents in nearly 100% of their patients. “We feel that these kinds of decisions are made because the physicians have a strong bias toward the drug-eluting stent technology,” he said. “It’s not because they have engaged patients in the decision-making process.”

In 2016, Chhatriwalla and colleagues published data highlighting some of these physician biases. They surveyed physicians who had used an individualized risk-assessment calculator for patients undergoing PCI. Although the risk model provided individualized, patient-specific estimates on mortality, bleeding, and restenosis risk, physicians tended to rely on their experience and subjective assessments rather than the objective risk calculator.

In the latest study, which included 317 subjects undergoing coronary angiography at two Kansas City, MO, hospitals between May 2014 and May 2015, those who prioritized avoiding the drawbacks of DAPT cited cost, having to take an additional medication, the potential for bleeding, and having to delay future surgeries as the reasons for wishing to avoid a prolonged regimen. Patients who solely valued avoiding DAPT—as opposed to valuing avoiding repeat procedures—were more likely to have undergone a PCI within a past 6 months, noted Chhatriwalla.

Patients in the study were not asked what type of stent they’d prefer, he stressed, but instead asked what factors were most and least important to them after coronary revascularization. Involving the patient in the shared decision-making process prior to PCI is rarely done, said Chhatriwalla

“It’s very fair to say that some patients don’t want to be part of the process,” he said. “There are a group of patients who say, ‘You’re the doctor, you know best.’” However, in past surveys, the majority of patients want to be involved in their own care on some level, Chhatriwalla said. He added that when he encounters a patient who prioritizes avoidance of DAPT even though they might be at a high risk for restenosis with a bare-metal stent, he tries to explain the trade-offs between the stent types.

A lot of times patients would be paralyzed by indecision because they just didn’t know and in the end would just say, ‘Well, what do you think?’ Chandan Devireddy

“I tell patients if they’re higher risk, from a medical standpoint, these drug-eluting stents are better. They reduce restenosis, but they’re the one who has to take the medicine,” said Chhatriwalla. “The more we engage patients and discuss these issues, the better we’re able to come to a decision that’s right for the patient. You can have the highest risk patient in the world, but if they won’t take their dual antiplatelet therapy, we shouldn’t be putting a drug-eluting stent in them.”

Paralyzed by Too Much Information

Chandan Devireddy, MD (Emory University School of Medicine, Atlanta, GA), who was not involved in the study, said physicians, including interventional cardiologists, are moving toward a patient-centered approach that takes into account the wishes of patients.

“In a perfect world, we would educate our patients as to everything’s that’s involved in terms of the choices we’re making for their bodies,” said Devireddy, a member of the Society for Cardiovascular Angiography and Interventions public relations committee. In a binary decision of a bare-metal versus a drug-eluting stent, physicians would provide patients with information about risk of restenosis, revascularization, and disability from angina, among other issues related to BMS use, versus the potential downsides of DAPT.

He said that despite intentions toward moving to shared decision-making, it’s not feasible for everybody. While some physicians might sometimes take a “more paternalistic approach than we should,” he has seen instances where the patient is overloaded with complex information, a situation that wasn’t uncommon in the days of first-generation stents when it was still unknown how long—1 year, 2 years, lifelong—DAPT would be needed.

“When we were having a lot more of these intricate conversations, a lot of times patients would be paralyzed by indecision because they just didn’t know and in the end would just say, ‘Well, what do you think?’” said Devireddy. “But now we’re talking about DAPT for 3 to 6 months, and it’s a very different conversation.”

Published reports have shown that patients can be resistant to taking additional drugs. For example, hypertensive patients often require two or three medications to lower their blood pressure and will resist adding another drug even though doing so can reduce the risk of MI and stroke. Naturally, this leaves physicians in a quandary, said Devireddy.

“The patient preference might be there, but is it founded in what is actually best for them? And should that even matter?” he told TCTMD. He noted that interventional cardiologists define “best” as freedom from revascularization, recurrent angina, and repeat procedures when selecting a drug-eluting stent over bare-metal stents, but the patient might have other priorities.