cardiology

Keeping on top of current medical literature and monitoring industry trends are essential ways we help ensure quality, affordable care for your members. By understanding how our industry evolves, we’re better able to tailor our solutions to meet the needs of your organization, your providers, and your members.

Created for health plan executives, our Trio series spotlights compelling trends in complex medical specialties for your organization. In this edition of Trio, Thomas Power, MD, National Medical Director for the AIM Cardiology Solution, presents three important trends in cardiology today.

Trend 1 – Overreliance on revascularization persists

Claudication is muscle pain that occurs during exercise due to the obstruction of arteries. Published evidence and professional society guidelines1 suggest that revascularization should be reserved for those who fail conservative management of claudication due to peripheral arterial disease (PAD). Conservative management includes lifestyle modification, structured exercise, and pharmacologic agents.

Although use of peripheral revascularization procedures is trending downwards, revascularization as a first-line therapy for claudication, without a trial of conservative management, is not uncommon2. This approach exposes patients to unnecessary procedural risks and radiation and is more costly.

To better manage care for your members, as of January 2023 our Cardiology Solution guidelines will include the management of revascularization for PAD with an update that guides providers to conservative treatment where clinically appropriate.

Trend 2 – Atherectomy use in management of PAD is increasing

For patients requiring endovascular revascularization for the management of claudication, there are three procedural options, balloon angioplasty, stent placement, and atherectomy. These may be used alone or in combination. A recent review of the literature3 indicates that atherectomy offers no benefit over balloon angioplasty with or without stenting. In fact, a 2019 review of the Vascular Quality Initiative registry4 found higher amputation rates in those who underwent atherectomy versus other procedures.

However, atherectomy utilization is increasing and, some providers routinely select atherectomy in preference to other procedures. This may be driven by higher reimbursement for atherectomy, but, regardless of the reason, current evidence does not support the practice.

At AIM, our January 2023 guideline update will include the management of endovascular revascularization and will help counter this trend by guiding providers away from use of atherectomy that is not medically necessary.

Trend 3 – Optimal therapy for patients with asymptomatic carotid stenosis remains undefined

Recent literature5 has focused on comparison of endarterectomy to carotid stenting as the optimal approach to management of carotid artery stenosis. However, an important upstream question remains unanswered–whether patients with asymptomatic carotid disease benefit from revascularization in addition to optimal medical therapy.

The evidence supporting use of carotid endarterectomy in asymptomatic patients is more than two decades old and in the interim, medical therapy has improved dramatically6. The risk-benefit ratio of carotid intervention for asymptomatic patients must now be re-evaluated in the light of the low annual stroke risk without intervention.


References

  1. Society for Vascular Surgery Lower Extremity Guidelines Writing Group, Conte MS, Pomposelli FB, et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication [published correction appears in J Vasc Surg. 2015 May;61(5):1382]. J Vasc Surg. 2015;61(3 Suppl):2S-41S.
  2. Hicks CW, Holscher CM, Wang P, Black JH 3rd, Abularrage CJ, Makary MA. Overuse of early peripheral vascular interventions for claudication. J Vasc Surg. 2020;71(1):121-130.e1.
  3. Wardle BG, Ambler GK, Radwan RW, Hinchliffe RJ, Twine CP. Atherectomy for peripheral arterial disease. Cochrane Database Syst Rev. 2020;9(9):CD006680. Published 2020 Sep 29.
  4. Ramkumar N, Martinez-Camblor P, Columbo JA, Osborne NH, Goodney PP, O’Malley AJ. Adverse Events After Atherectomy: Analyzing Long-Term Outcomes of Endovascular Lower Extremity Revascularization Techniques. J Am Heart Assoc. 2019;8(12):e012081.
  5. Müller MD, Lyrer P, Brown MM, Bonati LH. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Cochrane Database Syst Rev. 2020;2(2):CD000515. Published 2020 Feb 25.
  6. Paraskevas KI, Mikhailidis DP, Antignani PL, et al. Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement. J Stroke Cerebrovasc Dis. 2022;31(1):106182.

Thomas P. Power, MD, FACC, MRCPI, MBA

National Medical Director, Cardiology, Sleep Medicine, and Surgical Procedures

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