Lin Grace A, Dudley R Adams, Redberg Rita F
Division of General Internal Medicine, University of California-San Francisco School of Medicine, CA 94143-0124, USA.
Arch Intern Med. 2007;167(15):1604-9. doi: 10.1001/archinte.167.15.1604.
Percutaneous coronary intervention (PCI) is commonly performed in patients with stable coronary artery disease, despite current evidence suggesting that such patients derive minimal benefit from the procedure. We sought to determine the influences on cardiologists' decision to perform elective PCI in patients with stable coronary artery disease.
We conducted a qualitative study using 3 focus groups of interventional and noninterventional cardiologists in California. Participants discussed issues surrounding the decision to perform PCI using hypothetical case scenarios. We analyzed the data according to the principles of grounded theory.
Despite acknowledging data showing that PCI offers no reduction in the risk of death or myocardial infarction in patients with stable coronary artery disease, cardiologists generally believed that PCI would benefit such patients. Reasons given for performing PCI included belief in the benefits of treating ischemia and the open artery hypothesis, especially with drug-eluting stents; potential regret for not intervening if a cardiac event could be averted; alleviation of patient anxiety; and medicolegal considerations. Participants believed that, in patients undergoing coronary angiography, an "oculostenotic reflex" prevailed and all significant amenable stenoses would receive intervention, even in asymptomatic patients.
The widespread application of PCI in stable coronary artery disease for indications unsupported by evidence may reflect discordance between cardiologists' clinical knowledge and their beliefs about the benefits of PCI. Nonclinical factors appear to have substantial influence on physician decision making. Future studies should focus on the development of methods to help providers more fully incorporate clinical evidence into their medical decision making.
经皮冠状动脉介入治疗（PCI）常用于稳定型冠状动脉疾病患者，尽管目前证据表明此类患者从该手术中获益甚微。我们试图确定影响心脏病专家对稳定型冠状动脉疾病患者进行择期PCI决策的因素。
我们在加利福尼亚州对3组介入心脏病专家和非介入心脏病专家进行了定性研究。参与者使用假设病例场景讨论了围绕PCI决策的问题。我们根据扎根理论的原则分析了数据。
尽管承认有数据表明PCI并不能降低稳定型冠状动脉疾病患者的死亡或心肌梗死风险，但心脏病专家普遍认为PCI会使此类患者受益。进行PCI的理由包括相信治疗心肌缺血的益处和开放动脉假说，尤其是使用药物洗脱支架时；如果可以避免心脏事件而不进行干预可能会产生的遗憾；减轻患者焦虑；以及法医学考虑。参与者认为，在接受冠状动脉造影的患者中，“眼动脉狭窄反射”占主导地位，所有明显的可治疗狭窄都会接受干预，即使是无症状患者。
PCI在稳定型冠状动脉疾病中因缺乏证据支持的适应证而广泛应用，这可能反映了心脏病专家的临床知识与其对PCI益处的信念之间的不一致。非临床因素似乎对医生的决策有重大影响。未来的研究应侧重于开发方法，以帮助医疗服务提供者更充分地将临床证据纳入其医疗决策中。
