Search

Context: Limited data are available to guide cardiovascular screening in adult or masters athletes (≥35 years old). This review provides recommendations and the rationale for the cardiovascular risk assessment of older athletes. Evidence Acquisition: Review of available clinical guidelines, original investigations, and additional searches across PubMed for articles relevant to cardiovascular screening, risk assessment, and prevention in adult athletes (1990-2020). Study Design: Clinical review. Level of Evidence: Level 3. Results: Atherosclerotic coronary artery disease (CAD) is the leading cause of exercise-induced acute coronary syndromes, myocardial infarction, and sudden cardiac death in older athletes. Approximately 50% of adult patients who experience acute coronary syndromes and sudden cardiac arrest do not have prodromal symptoms of myocardial ischemia. The risk of atherosclerotic cardiovascular disease (ASCVD) can be estimated by using existing risk calculators. ASCVD 10-year risk is stratified into 3 categories: low-risk (≤10%), intermediate-risk (between 10% and 20%), and high-risk (≥20%). Coronary artery calcium (CAC) scoring with noncontrast computed tomography provides a noninvasive measure of subclinical CAD. Evidence supports a significant association between elevated CAC and the risk of future cardiovascular events, independent of traditional risk factors or symptoms. Statin therapy is recommended for primary prevention if 10-year ASCVD risk is ≥10% (intermediate- or high-risk patients) or if the Agatston score is >100 or >75th percentile for age and sex. Routine stress testing in asymptomatic, low-risk patients is not recommended. Conclusion: We propose a comprehensive risk assessment for older athletes that combines conventional and novel risk factors for ASCVD, a 12-lead resting electrocardiogram, and a CAC score. Available risk calculators provide a 10-year estimate of ASCVD risk allowing for risk stratification and targeted management strategies. CAC scoring can refine risk estimates to improve the selection of patients for initiation or avoidance of pharmacological therapy.

Coronary artery perforation is an uncommon, but potentially devastating, complication of PCI, and is observed most frequently in complex procedures. Clinical outcomes, including periprocedural and long-term mortality, are markedly worse with increasing degree of perforation. Perforation required covered stent usage predicts a high in-hospital and overall mortality, although no difference is noted between covered stent type.

Treatment of bifurcation lesions has advanced with the development of second-generation drug-eluting stents and state-of-the-art percutaneous coronary interventions techniques. This subanalysis of SYNTAX II demonstrates similar major adverse cardiac or cerebrovascular events in patients with bifurcation and nonbifurcation lesions, with a trend toward higher target lesion failure in the bifurcation cohort. The results, while compelling, require larger studies with longer follow-up, stratified by bifurcation strategy.

Stroke occurs infrequently following percutaneous coronary intervention (PCI) with 30-day and 1-year cumulative incidence of 0.4 and 1.5%, respectively. Patient comorbidities, acute presentations, and complex coronary lesions are more prevalent among patients who sustain a stroke. The occurrence of stroke is associated with higher short-term and overall mortality compared with bleeding or myocardial infarction.

Lead barriers to reduce operator radiation exposure in the catheterization laboratory are effective. This study of a novel vertical radiation shield suggests significant reduction in operator radiation exposure when used in addition to standard protection methods. Although additional barriers may help reduce radiation exposure, further education and training of operators in radiation safety may be as effective and perhaps more effective than additional barriers.

Prosthesis-patient mismatch (PPM) is defined as a small effective orifice area (EOA) of a normally functioning prosthetic valve in relation to patient body size. Even moderate impediment to forward flow has been associated with an increase in all-cause mortality. We report an unusual cause of PPM where a transcatheter implantation of a large EOA valve in an aortic position results in relative PPM in a patient with morbid obesity. © 2016 Wiley Periodicals, Inc.

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document

Endothelial progenitor cells (EPCs) may allow accelerated and functional endothelialization of stents, theoretically reducing late stent complications as well reducing the duration of DAPT. In a pilot study of 193 patients at high risk of target vessel failure (TVF), the Genous EPC capturing stent (ESC) and TAXUS Liberte paclitaxel-eluting second-generation stent (PES) were similar at 5-years. Events rates appear higher for ESC within the first-year followed by higher rate of complications for PES during years 2-5. A larger randomized multi-center trials powered for non-inferiority of ECS to PES is underway.

The authors suggest that the early durability of the CoreValve implant should not be in question based on the results of this modestly sized, but well-done postmortem observational study. Given the ever-expanding knowledge of valvular degeneration, one thing is clear: more research and study is needed before any routine change in clinical practice, such as change it antithrombotic therapy, can be recommended. Further autopsy studies of patients who die outside of typical healthcare settings and who have had a longer median implant time would aid greatly in furthering the understanding of the degeneration and natural history of bioprosthetic transcatheter heart valves.

Robotic-assisted PCI appears to be safe and feasible in both simple and complex lesions. In this small cohort study, analysis of manual versus robotic PCI suggests comparable clinical outcomes. Further adequately powered, randomized, multicenter studies are needed to definitively evaluate outcomes in manual versus robotic-assisted PCI.

As indications for TAVR expand, there is a need for predictive models of procedural complications. Application of the HAS-BLED score demonstrated patient comorbidities that contribute to increased bleeding events and mortality. Further adequately powered studies will be needed to validate the HAS-BLED score for use in the TAVR population or further elucidate important risk factor to incorporate into future predictive risk models.

The Appropriate Use Criteria for Coronary Revascularization (AUC) were created in 2009 [1,2] and updated in 2012 [3] through a rigorous process and then endorsed by major cardiovascular societies. The AUC were developed from a limited set of carefully defined clinical scenarios; they were not envisioned as covering every clinical situation, but rather, descriptive of common ones. The AUC have become widely accepted as one component of decision making, along with published clinical guidelines, physician experience, and patient preference. Regrettably, they have also come to be seen as an instrument for directing insurance coverage policy. While the original AUC document [1,2] noted “it is hoped that payors would use these criteria as the basis for the development of rational payment management strategies to ensure that their members receive necessary, beneficial, and costeffective cardiovascular care,” denial of coverage in individual cases based on the AUC category was not an intended purpose. In addition, the 2012 update [3] explicitly states that some inappropriate indications should be reimbursed and that the uncertain rating does not justify denial of payment. Policymakers and payors must be good stewards of the insurance system, and are increasingly challenged to find innovative ways to curb expenditures. Thus, it is tempting for them to view the AUC as a professionally mandated tool for “cost-cutting” [4]. SCAI and its members recognize the essential need for prudent cost management but are very concerned with this unanticipated and detrimental approach to coverage determinations. This SCAI position statement addresses our members’ apprehension that the application of AUC by many payors without consideration of other features of the patient’s medical condition is far beyond the intent of the AUC, and has the potential for significant unintended consequences for patients and hospitals. Accordingly, this position statement outlines SCAI’s recommendations regarding the use of AUC in making coverage determinations for percutaneous coronary intervention (PCI) procedures. SCAI and its members have several concerns. First, although the AUC may be useful in helping to guide insurance coverage, the AUC classification should not be the solitary reason used to deny coverage. Such unjustifiable application of AUC might be harmful to patients, and could be contrary to shared decision

As indications for TAVR continue to grow, experienced centers strive to adopt further minimally invasive techniques and continue to improve outcomes. Meta-analysis of the available data demonstrate that conscious sedation is associated with decreased ICU and hospitalization time, and is not associated with decreased procedural efficacy or safety. Randomized Controlled clinical Trial data will be needed to confirm observational findings suggesting decreased mortality with conscious sedation versus general anesthesia.

This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines. A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Authors suggest the use of an investigator-owned and directed, prospective, non-randomized, single-arm multicenter registry at 23 Italian hospitals to follow 500 STEMI patients who receive BVS. Follow-up of patients is out to 5 years to determine how a BVS which has been deployed according to the IFU performs in these ACS patients. There is no comparator arm. Mandate that patients included in this registry follow a strict BVS implantation protocol which is felt to mitigate the not insignificant stent thrombosis rates noted with BVS to date.

Background Second‐generation drug eluting stents (DES) may reduce costs and improve clinical outcomes compared to first‐generation DES with improved cost‐effectiveness when compared to bare metal stents (BMS). We aimed to conduct an economic evaluation of a cobalt‐chromium everolimus eluting stent (Co‐Cr EES) compared with BMS in percutaneous coronary intervention (PCI). Objective To conduct a cost‐effectiveness analysis (CEA) of a cobalt‐chromium everolimus eluting stent (Co‐Cr EES) versus BMS in PCI. Methods A Markov state transition model with a 2‐year time horizon was applied from a US Medicare setting with patients undergoing PCI with Co‐Cr EES or BMS. Baseline characteristics, treatment effects, and safety measures were taken from a patient level meta‐analysis of 5 RCTs (n = 4,896). The base‐case analysis evaluated stent‐related outcomes; a secondary analysis considered the broader set of outcomes reported in the meta‐analysis. Results The base‐case and secondary analyses reported an additional 0.018 and 0.013 quality‐adjusted life years (QALYs) and cost savings of $236 and $288, respectively with Co‐Cr EES versus BMS. Results were robust to sensitivity analyses and were most sensitive to the price of clopidogrel. In the probabilistic sensitivity analysis, Co‐Cr EES was associated with a greater than 99% chance of being cost saving or cost effective (at a cost per QALY threshold of $50,000) versus BMS. Conclusions Using data from a recent patient level meta‐analysis and contemporary cost data, this analysis found that PCI with Co‐Cr EES is more effective and less costly than PCI with BMS. © 2016 The Authors. Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.

With the plethora of clinical trials, it is difficult for busy interventional cardiologists to stay up to date. Therefore, the SCAI publications committee concisely summarizes and provides editorial commentary on the most important trials from recent, large international meetings. The intent is to provide this summary every six months to allow quick assimilation of trial results into interventional practice. © 2014 Wiley Periodicals, Inc.

With the evolution of transcatheter valve replacement, an important opportunity has arisen for cardiologists and surgeons to collaborate in identifying the criteria for performing these procedures. Therefore, The Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), and The Society of Thoracic Surgeons (STS) have partnered to provide recommendations for institutions to assess their potential for instituting and/or maintaining a transcatheter valve program. This article concerns transcatheter pulmonic valve replacement (tPVR). tPVR procedures are in their infancy with few reports available on which to base an expert consensus statement. Therefore, many of these recommendations are based on expert consensus and the few reports available. As the procedures evolve, technology advances, experience grows, and more data accumulate, there will certainly be a need to update this consensus statement. The writing committee and participating societies believe that the recommendations in this report serve as appropriate requisites. In some ways, these recommendations apply to institutions more than to individuals. There is a strong consensus that these new valve therapies are best performed using a Heart Team approach; thus, these credentialing criteria should be applied at the institutional level. Partnering societies used the ACC's policy on relationships with industry (RWI) and other entities to author this document (http://www.acc.org/guidelines/about-guidelines-and-clinical-documents). To avoid actual, potential, or perceived conflicts of interest due to industry relationships or personal interests, all members of the writing committee, as well as peer reviewers of the document, were asked to disclose all current healthcare-related relationships including those existing 12 months before the initiation of the writing effort. A committee of interventional cardiologists and surgeons was formed to include a majority of members with no relevant RWI and to be led by an interventional cardiology cochair and a surgical cochair with no relevant RWI. Authors with relevant RWI were not permitted to draft or vote on text or recommendations pertaining to their RWI. RWI were reviewed on all conference calls and updated as changes occurred. Author and peer reviewer RWI pertinent to this document are disclosed in the Appendices. In addition, to ensure complete transparency, authors' comprehensive disclosure information (including RWI not pertinent to this document) is available in Appendix AII. The work of the writing committee was supported exclusively by the partnering societies without commercial support. SCAI, AATS, ACC, and STS believe that adherence to these recommendations will maximize the chances that these therapies will become a successful part of the armamentarium for treating valvular heart disease in the United States. In addition, these recommendations will hopefully facilitate optimum quality during the delivery of this therapy, which will be important to the development and successful implementation of future, less invasive approaches to structural heart disease.

With the plethora of clinical trials, it is difficult for busy interventional cardiologists to stay up to date. Therefore, the Society for Cardiovascular Angiography and Interventions (SCAI) publications committee concisely summarized and provided editorial commentary on the most important trials from recent, large international meetings. The intent is to provide this summary every six months to allow quick assimilation of trial results into interventional practice.

Transcatheter aortic valve replacement is being used with increasing frequency in patients with severe aortic stenosis who are otherwise deemed to be at high surgical risk. Aortic dissection is a rare complication of transcatheter aortic valve replacement and poses a unique management dilemma. We describe the treatment of an acute Stanford type A aortic dissection after transcatheter aortic valve replacement with a modified thoracic endovascular stent graft in a 95-year-old woman.

Increasing annular calcification portends more adverse outcomes and worse hemodynamic results following percutaneous structural heart interventions. Though the Direct Flow prosthesis did not appear to have significantly different post-procedural gradients based on aortic valve calcium burden in a selected group of patients, the average residual gradients were relatively high in all cases and the presence of a paravalvular leak was more common with increasing valvular calcification. It is unclear how the Direct Flow prosthesis fits into the armamentarium of TAVR prostheses.

The TRYTON study evaluated routine side branch (SB) stenting with a novel bare metal stent (BMS) designed for true bifurcation lesions (Medina 1,1,1; 1,0,1; 0,1,1) and compared it to a strategy of balloon angioplasty with provisional stenting. It failed to meet the primary endpoint of non-inferiority in target vessel failure mainly driven by peri-procedural myocardial infarction (MI) with elevated CK-MB 3× the upper limit of normal. In this substudy, 41% of patients who had a SB diameter 2.25 mm were evaluated and the new stent was found to be non-inferior in the primary outcome of target vessel failure with no difference in post-procedural MI. This substudy suggests that appropriately sized SB stents with TRYTON may be useful when the SB is2.25 mm in diameter. However, further studies could evaluate routine use of FFR for SBs; drug eluting versions of the stent as well as stents designed for vessels 2.25 mm in diameter which are frequently felt to be clinically larger when not subjected to core lab analysis.

Subintimal tracking and reentry (STAR) has been used as a bailout strategy and involves an uncontrolled dissection and recanalization into the distal lumen to reestablish vessel patency. In the current study, thrombolysis in myocardial infarction (TIMI) flow 3 was the only variable which they found to be significantly associated with restenosis and reocclusion after stent placement. It may be reasonable to consider second generation drug eluting stent placement in patients receiving STAR that have TIMI 3 flow, however, this should only be done if there is no compromise of major side branches. If unsure, we recommend to perform balloon angioplasty without stenting.

A 55-year-old male underwent paclitaxel-eluting stent implantation in a bifurcation lesion of his left anterior descending artery (LAD) during an episode of unstable angina in 2008. A late in-stent restenosis developed 15 months after implantation of the drug-eluting stent (DES) and was treated with paclitaxel eluting balloon. Two months later, during angiography for functional assessment of the significance of lesions in the circumflex artery, an aneurysm at the place of drug-eluting balloon (DEB) inflation was observed. The patient was left on double antiplatelet therapy and scheduled for clinical observation after 3 months and control coronary angiography after 6 months for aneurysm progression follow-up.

Key Points Pressure-bound (pb) coronary flow reserve (CFR) is a novel estimation of CFR, calculated from easily obtained baseline and hyperemic pressure assessment Validation of pb-CFR in previously reported lesions showed accuracy of 84% to CFR with sensitivity of 96% and specificity of 60% FFR >0.75 and low pb-CFR in DEFER was associated with increased angina and complications compared to high pb-CFR and this risk was not modified by elective revascularization.

The introduction of coronary stents marked a major turning point in the practice of interventional cardiology. Whereas the efficacy of balloon angioplasty was challenged both by immediate mechanical complications and by a high incidence of restenosis, coronary stents offered cardiologists a means by which to not only augment immediate procedural success, but also to reduce the incidence of restenosis following coronary intervention. However, despite technological advances and an improved understanding of the restenotic process, the overall rate of in-stent restenosis following bare metal stent implantation remains high. Although the introduction of drug-eluting stents has further reduced the incidence of restenosis, the "real-world" application of drug-eluting stents in increasingly complex lesion and patient subsets has given way to the even greater clinical challenge of managing drug-eluting stent restenosis. Although the standard treatment of bare metal stent restenosis typically involves placement of a drug-eluting stent, the optimal therapeutic approach to drug-eluting stent restenosis remains less defined. The issue of in-stent restenosis (especially following implantation of a drug-eluting stent) remains a clinical challenge, and investigation into therapeutic options remains ongoing. As technology evolves, such investigation will likely incorporate novel approaches including drug-coated balloons novel stent designs.

Provisional use of rotational atherectomy (RA) is indicated for procedural success in heavily calcified lesions. In the current study, RA use at three high volume percutaneous coronary intervention (PCI) centers between 2005 and 2013 was 1.4%. MACE rate was 17.8% at median follow-up of 22 months. Peripheral vascular disease (PVD), diabetes mellitus (DM), acute coronary syndrome (ACS), and SYNTAX23 were found to be independently associated with MACE. With increasing complexity of disease and SYNTAX score, there is usually an increase in severity of calcification and need for atherectomy. Complete revascularization with residual SYNTAX reduced to 8 is associated with improved outcomes. Incompleteness of revascularization in patients with SYNTAX33 rather than procedural success of the target vessel with atherectomy may have contributed to the adverse outcomes.

Increasing annular calcification portends more adverse outcomes and worse hemodynamic results following percutaneous structural heart interventions. Though the Direct Flow prosthesis did not appear to have significantly different post-procedural gradients based on aortic valve calcium burden in a selected group of patients, the average residual gradients were relatively high in all cases and the presence of a paravalvular leak was more common with increasing valvular calcification. It is unclear how the Direct Flow prosthesis fits into the armamentarium of TAVR prostheses.

Key Points Provisional use of rotational atherectomy (RA) is indicated for procedural success in heavily calcified lesions. In the current study, RA use at three high volume percutaneous coronary intervention (PCI) centers between 2005 and 2013 was 1.4%. MACE rate was 17.8% at median follow-up of 22 months. Peripheral vascular disease (PVD), diabetes mellitus (DM), acute coronary syndrome (ACS), and SYNTAX > 23 were found to be independently associated with MACE. With increasing complexity of disease and SYNTAX score, there is usually an increase in severity of calcification and need for atherectomy. Complete revascularization with residual SYNTAX reduced to 33 rather than procedural success of the target vessel with atherectomy may have contributed to the adverse outcomes.

Subintimal tracking and reentry (STAR) has been used as a bailout strategy and involves an uncontrolled dissection and recanalization into the distal lumen to reestablish vessel patency. In the current study, thrombolysis in myocardial infarction (TIMI) flow

Background This study describes short-term and mid-term outcomes of nonagenarian patients undergoing transfemoral or transapical transcatheter aortic valve replacement (TAVR) in the Placement of Aortic Transcatheter Valve (PARTNER)-I trial. Methods From April 2007 to February 2012, 531 nonagenarians, mean age 93 ± 2.1 years, underwent TAVR with a balloon-expandable prosthesis in the PARTNER-I trial: 329 through transfemoral (TF-TAVR) and 202 transapical (TA-TAVR) access. Clinical events were adjudicated and echocardiographic results analyzed in a core laboratory. Quality of life (QoL) data were obtained up to 1 year post-TAVR. Time-varying all-cause mortality was referenced to that of an age-sex-race–matched US population. Results For TF-TAVR, post-procedure 30-day stroke risk was 3.6%; major adverse events occurred in 35% of patients; 30-day paravalvular leak was greater than moderate in 1.4%; median post-procedure length of stay (LOS) was 5 days. Thirty-day mortality was 4.0% and 3-year mortality 48% (44% for the matched population). By 6 months, most QoL measures had stabilized at a level considerably better than baseline, with Kansas City Cardiomyopathy Questionnaire (KCCQ) 72 ± 21. For TA-TAVR, post-procedure 30-day stroke risk was 2.0%; major adverse events 32%; 30-day paravalvular leak was greater than moderate in 0.61%; and median post-procedure LOS was 8 days. Thirty-day mortality was 12% and 3-year mortality 54% (42% for the matched population); KCCQ was 73 ± 23. Conclusions A TAVR can be performed in nonagenarians with acceptable short- and mid-term outcomes. Although TF- and TA-TAVR outcomes are not directly comparable, TA-TAVR appears to carry a higher risk of early death without a difference in intermediate-term mortality. Age alone should not preclude referral for TAVR in nonagenarians.

Maryland state agencies and the U.S. Attorney’s Office for Medicare Fraud have launched a full-fledged investigation of alleged inappropriate use of percutaneous coronary intervention (PCI) by a small number of operators and allegations of substantial overutilization of stents at several Maryland hospitals (1). In addition, an ongoing investigation under the auspices of the Maryland Department of Health and Mental Hygiene and other regulatory agencies is in full operation. A final report is due before the Maryland state legislature reconvenes in January. In an effort to proactively respond to these allegations, the Maryland Chapter of the American College of Cardiology (ACC), in close partnership with the national ACC and the Society for Cardiovascular Angiography and Interventions (SCAI), developed a task force charged with restoring patient confidence and assuring Maryland lawmakers that processes can be put in place at hospitals to closely monitor cardiac catheterization laboratories (cath labs) and prevent similar allegations going forward. To date, the task force has met with all levels of state government, including the Maryland governor’s office, and has drafted innovative legislation regarding the oversight required to ensure delivery of optimal high-quality cardiovascular care in the state. The proposed legislation, entitled “The Maryland Cardiovascular Patient Safety Act 2011,” has several prominent supporters in both the Maryland House and Senate and provides an opportunity consistent with the goal of patient-centered, quality care. More importantly, it will provide assurance to a wary public through independent cath lab accreditation. The issues facing Maryland hospitals and cardiovascular professionals present an opportunity to illustrate how professional societies can take a leadership role in ensuring quality care in the areas of peer review, accreditation, and data management. The issue of quality and appropriateness of cardiovascular care has not been confined to the state of Maryland or to the field of interventional medicine. We have seen other high profile allegations of overutilization and questions of appropriateness across the country in reference to other areas of cardiovascular care (and, indeed, in numerous other areas of medical care). It is time for our profession to step forward locally, regionally, and nationally to take the leadership position in this vital area of patient care. This is a natural progression, since for many years, cardiovascular professional societies—and the field of cardiology in general—have been well ahead of other specialties in producing data from clinical registries and in developing quality and appropriateness guidelines (2). Internal peer review is the crux of a successful cardiovascular program, regardless of whether it is related to invasive or noninvasive disciplines. It is critical that peer review be performed in a standardized, impartial, and effective manner. Present processes for internal peer review in some hospitals are inadequate if not faulty. Internal processes must be clear, rigorous, and objective, selecting random cases and guarding against physicians reviewing their own cases. Cases need to be reviewed not only in terms of outcome measures but also on the basis of appropriateness. A standardized internal process must be followed by independent external oversight performed by an external physician body.