ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease

Abstract

along with key specialty and subspecialty societies, have completed a 2-part revision of the appropriate use criteria (AUC) for coronary revascularization. In prior coronary revascularization AUC documents, indications for revascularization in acute coronary syndromes and stable ischemic heart disease (SIHD) were combined into 1 document. To address the expanding clinical indications for coronary revascularization, and to align the subject matter with the most current American College of Cardiology/American Heart Association guidelines, the new AUC for coronary artery revascularization were separated into 2 documents addressing SIHD and acute coronary syndromes individually. This document presents the AUC for SIHD.Clinical scenarios were developed to mimic patient presentations encountered in everyday practice. These scenarios included information on symptom status; risk level as assessed by noninvasive testing; coronary disease burden; and, in some scenarios, fractional flow reserve ASNC testing, presence or absence of diabetes, and SYNTAX score. This update provides a reassessment of clinical scenarios that the writing group felt were 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 but employs the recent modifications in the methods for developing AUC, most notably, alterations in the nomenclature for appropriate use categorization.A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with high symptom burden, high-risk features, and high coronary disease burden, as well as in patients receiving antianginal therapy, are deemed appropriate. Additionally, scenarios assessing the appropriateness of revascularization before kidney transplantation or transcatheter valve therapy are now rated. The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making.

Ischemia and No Obstructive Coronary Artery Disease (INOCA): What Is the Risk?

“…These stable patients typically have symptoms of chest pain suspected to be angina and/or abnormal stress testing, in the setting of no obstructive CAD at coronary angiography 1, 2. The definition of obstructive CAD varies between different guidelines or studies 3, 4, 5, 6, 7, 8, 9, 10. In general, “normal”‐appearing coronary arteries are defined as 0% luminal stenosis or <20%, and non–obstructive CAD (NOCAD) is defined as luminal stenosis >20% but <50% 3, 8, 9, 10.…”

“…However, some studies use a threshold of <70% for NOCAD,4 while anatomical scores consider a stenosis ≥50% as significant 5, 6, 11. Traditional understanding of obstructive CAD was 70%12; however, recent European Society of Cardiology and American College of Cardiology/American Heart Association (ACC/AHA) guidelines shifted to include stenosis of 50% to 70% if there is associated inducible ischemia or fractional flow reserve ≤0.08 when considering the physiological significance of stenosis and revascularization management in patients with stable CAD 6, 7…”

Screening coronary angiography in patients with long‐standing diabetes mellitus undergoing kidney transplant evaluation

“…The recent AUC on coronary intervention from ACC/AHA does not take into consideration the indication for angiography but does consider the lesion type (proximal LAD, left main involvement) and presence of DM. While the recommendations are largely based on patient‐reported symptoms and results of noninvasive stress testing, the AUC do recommend incorporating fractional flow reserve (FFR) if no prior stress tests are available. Using FFR‐based intervention has been shown to decrease rates of urgent revascularization and MACE in the general population .…”

“…have included a heterogeneous group of patients, often combining patients with and without DM, and those with and without CAD. [6][7][8][9] In patients with poor or unknown functional capacity (<4 METS) who are undergoing kidney transplant evaluation, the recent ACC/ AHA guidelines on preoperative screening for ischemic heart disease considers the use of stress radionuclide imaging and stress echocardiography as "appropriate use" 23 Furthermore, the AUC guidelines consider the use of screening coronary angiography prior to solid organ transplantation as "may be appropriate" (previously denoted as "uncertain") in selected circumstances. 15 Our study was designed to answer the question of whether a coronary angiogram F I G U R E 2 Area under the curve for the model predicting the need for coronary intervention was 0.803 needs to be considered in addition to noninvasive stress testing and functional assessment in certain high-risk populations, specifically long-standing diabetic patients who come to the clinic for a kidney transplant evaluation.…”

Modern considerations of myocardial revascularization in coronary chronic total occlusion

“…Нормокинез и гипокинез миокарда в зоне окклюзии по определению исключает отсутствие жизнеспособного миокарда. При наличии жизнеспособного миокарда в зоне окклюзии, ЧКВ на ХОКА показано у пациентов с резистентной к ОМТ стенокардией [15,16]. Согласно рекомендациям европейского общества кардиологов, ЧКВ на ХОКА показана при наличии зоны ишемии миокарда >10% от объема левого желудочка (ЛЖ), вне зависимости от наличия симптомов.…”