It is now becoming common for an interventional cardiologist to be faced with the prospect of performing percutaneous coronary intervention (PCI) on patients with a variety of serious clinical problems, such as advanced age, significant co-morbidity, cardiogenic shock or contraindications for coronary artery bypass surgery. What is the operator to do? At the very least, he or she has to explain the risks of performing (and, indeed, not performing) the procedure to the patient in order to obtain fully informed consent. Ultimately, he must also retain the right not to perform the procedure personally at all. Perhaps he should seek a second opinion, or assistance from a more experienced colleague. How are these decisions to be made? Do we have any guidance?

Cardiac surgeons are accustomed to using formal scoring systems such as Parsonnet and EuroScore to assist them in their decision-making.^1,2 Both systems are well known to have their drawbacks. Nevertheless, they offer a common currency of terminology and some degree of precision to assist the surgeon, the patient and their family in the difficult decisions associated with undertaking open heart surgery. Why does PCI not have such a system? Somewhat surprisingly, it does. In fact, it has several. What it seems to lack is a willingness (or incentive) to use one of them.

NEW YORK RISK SCORE

The latest, and possibly the most convincing, in terms of contemporary practice and the sheer numbers of patients studied, has just been published in the Journal of the American College of Cardiology.³ In this paper, no less than 46 090 PCI procedures, performed in 41 hospitals …