Context Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown. Objective To assess the appropriateness of PCI in the United States. Design, Setting, and Patients Multicenter, prospective study of patients within the National Cardiovascular Data Registry undergoing PCI between July 1, 2009, and September 30, 2010, at 1091 US hospitals. The appropriateness of PCI was adjudicated using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non–ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication. Main Outcome Measures Proportion of acute and nonacute PCIs classified as appropriate, uncertain, or inappropriate; extent of hospital-level variation in inappropriate procedures. Results Of 500 154 PCIs, 355 417 (71.1%) were for acute indications (ST-segment elevation myocardial infarction, 103 245 [20.6%]; non–ST-segment elevation myocardial infarction, 105 708 [21.1%]; high-risk unstable angina, 146 464 [29.3%]), and 144 737 (28.9%) for nonacute indications. For acute indications, 350 469 PCIs (98.6%) were classified as appropriate, 1055 (0.3%) as uncertain, and 3893 (1.1%) as inappropriate. For nonacute indications, 72 911 PCIs (50.4%) were classified as appropriate, 54 988 (38.0%) as uncertain, and 16 838 (11.6%) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), or suboptimal (≤1 medication) antianginal therapy (95.8%). Furthermore, although variation in the proportion of inappropriate PCI across hospitals was minimal for acute procedures, there was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%–16.7%). Conclusions In this large contemporary US cohort, nearly all acute PCIs were classified as appropriate. For nonacute indications, however, 12% were classified as inappropriate, with substantial variation across hospitals.

Intense investigation continues on the pathobiology of stent thrombosis (ST) because of its morbidity and mortality. Because little advance has been made in outcomes following ST, ongoing research is focused on further understanding predictive factors as well as ST frequency and timing in various patient subsets, depending upon whether a drug-eluting stent or bare-metal stent has been implanted. Although the preventive role of antiplatelet therapies remains unchallenged, new data on genomics and variability in response to antiplatelet therapy, as well as the effects of novel therapeutic agents and duration of therapy, have become available. The goal remains identification of patients at particularly increased risk of ST so that optimal prevention strategies can be developed and employed.

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The 2010 audits provided evidence that many fields in the NCDR accurately represent the data from the medical charts. The American College of Cardiology Foundation is undertaking a series of initiatives aimed at creating a quality assurance rapid learning system, which, when complete, will monitor, evaluate, and improve data quality.

Data from the CathPCI Registry provide a contemporary view of the current practice of invasive cardiology in the United States.

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an update of the appropriate use criteria (AUC) for coronary revascularization frequently considered. In the initial document, 180 clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. This update provides a reassessment of clinical scenarios the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document, and the definition of appropriateness was unchanged. The technical panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate and likely to improve patients' health outcomes or survival. Scores of 1 to 3 indicate revascularization is considered inappropriate and unlikely to improve health outcomes or survival. Scores in the mid-range (4 to 6) indicate a clinical scenario for which the likelihood that coronary revascularization will improve health outcomes or survival is uncertain. In general, as seen with the prior AUC, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally,percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.

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SUMMARY Left ventricular (LV) performance at rest and during multilevel exercise in the supine and upright positions was studied in seven normal subjects with equilibrium radionuclide ventriculography. The mean left ventricular end-diastolic volume (LVEDV) during supine rest was 107 4 10 ml (± SEM) and 85 ± 6 ml (p < 0.02) in the upright position; the mean resting left ventricular end-systolic volumes (LVESV) were not diSferent in the upright and supine positions. The Changes in posture at rest are associated with significant changes in LV filling and stroke volume. A transition from the supine to the upright position produces a decrease in LV end-diastolic pressure1-3 and volume4-6 and in stroke volume.' -4 6-10 The results of previous studies of the alterations in LV enddiastolic volume during exercise in the supine position have varied.5, 6, 11-15 There is general agreement that end-systolic volume is smaller during exercise than at rest;6 11, 12, 14,15 most investigators3' 6, 12, 13 have reported an exercise-induced increase in stroke volume, although others have not.1 4These data are generally consistent with an enhanced contractile state From the Departments of Medicine