ABC | Volume 112, Nº5, May 2019

Original Article Luciano et al Analysis of coronariographies in Southern Brazil Arq Bras Cardiol. 2019; 112(5):526-531 Table 3 – Distribution of patients being investigated for CAD within the two institutions according to gender, assessment of appropriation, reason for indication, result of coronary angiogram and treatment Source Hospital A Hospital B Score n = 125 % Score n = 191 % Gender Female 51 40.8% 72 37.7% p = 0.580 Male 74 59.2% 119 62.3% Evaluation of Appropriation Appropriate 54 43.2% 119 62.3% p <0.001 Occasionally Appropriate 61 48.8% 50 26.2% p <0.001 Rarely Appropriate 10 8% 22 11.5% p = 0.317 Reason for Indication Diagnosis of CAD 97 77.6% 114 59.7% p <0.001 Reassessment of CAD 14 11.2% 33 17.3% p = 0.146 Pre-Op. of Cardiac Surgery 6 4.8% 40 20.9% p <0.001 Pre-Op. of Non-Cardiac Surgery 8 6.4% 4 2.1% p = 0.049 Result Normal 80 64% 118 61.8% p = 0.690 Single-vessel 26 20.8% 38 19.9% p = 0.844 Two-vessel 12 9.6% 19 9.9% p = 0.919 Three-vessel 6 4.8% 14 7.3% p = 0.366 LCT 1 0.8% 2 1% p = 0.824 Treatment Clinical 102 81.6% 152 79.6% p = 0.658 Angioplasty 12 9.6% 20 10.5% p = 0.801 Surgical 11 8.8% 19 9.9% p = 0.733 CAD: coronary artery disease; LCT: left coronary artery trunk. * Statistical significance analyzes performed using the chi-square test. were indicated for clinical treatment. Of the seven patients, in four (57.1%) lesions were observed in vessels of fine caliber (< 2 mm); in two (28.6%), there were distal lesions in vessels of fine caliber, and one (14.3%) underwent coronary angiography due to moderate aortic valve stenosis, being asymptomatic from the cardiological point of view. In 13.5% of those classified as occasionally appropriate, and in 43.8% of the appropriate, the option was either percutaneous or surgical revascularization. Discussion The balance between cost and effectiveness is necessary because funding sources are pressed by increased demand, technology, and consequently, resources. The rational use of these resources is part of the physician's social responsibility. 4 Even so, many cardiologists believe that angioplasty is beneficial for patients with stable CAD, and the approach continues to be the search for ischemia. It is not surprising that a substantial minority of cardiologists believe that angioplasty and coronary stenting prevent myocardial infarction. These beliefs are seen in practice with poor application of resources: it is estimated that up to half of elective angioplasties may be inappropriate. 14 This reality also applies to diagnostic methods, such as coronary angiography. 7,9 Historically there is great international variability in the proper use of diagnostic cardiac catheterization. This issue was studied in more than ten countries between 1987 and 2006, with appropriate use rates between 34.5% 7 and 91%, 15 with most studies showing rates of appropriation above 72%. 16 Differently from other large multicenter retrospective studies analyzing the 2012 guideline for appropriate use of diagnostic cardiac catheterization, 9,10 the present study validates the guideline when we relate the adequacy of coronary angiography and the treatment. Another relevant aspect is the possibility of analyzing the characteristics of two institutions with different profiles (general tertiary hospital and tertiary cardiology hospital) within the same micro‑region. In addition, although the 2012 guideline still uses the classification of appropriate, uncertain and inappropriate, we chose to use the most current classification of appropriate, occasionally appropriate and rarely appropriate, used in the most recent guidelines. 11 We included the cases of ACS in our analysis, which were not included in other studies, because it is the subgroup of patients that accounts for the main difference between the centers studied, and due to the relevance of documenting these institutional characteristics. The cases of ACS do not qualitatively stratify coronary angiography indications, since, in these cases, all of them are classified as appropriate. We observed the expected predominance of these cases in the cardiology hospital (Hospital B), and higher prevalence of stable patients in the general hospital (Hospital A) (Table 1). To analyze the quality of the indications for coronary angiography, the analysis of the subgroup of patients in the CAD investigation was performed. 529