ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update

Abstract

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.

Temporal Trends in Percutaneous Coronary Intervention Appropriateness

“…1,2 In response to pressures to reduce inappropriate use of PCI, providers may be motivated to inflate clinical acuity or patient-reported symptoms to influence apparent appropriateness. This may result in the appearance of more frequent use of PCI for higher-acuity clinical indications with concurrent declining inappropriate use.…”

“…Details on the AUC have previously been published. 1,2,10 In these criteria, PCI is considered inappropriate when the procedure is unlikely to improve the patient's health status (symptoms, functional status, or quality of life) or survival.…”

“…The appropriate use criteria (AUC) for coronary revascularization support an evidence-based guidelines-concordant approach to assessing the quality of patient selection for percutaneous coronary intervention (PCI). 1,2 In these criteria, inappropriate PCIs reflect clinical scenarios in which the patient's health status (symptoms, function, or quality of life) or survival is unlikely to be improved by the procedure. Application of the AUC has demonstrated quality gaps in patient selection for PCI, with as many as 1 in 6 elective (nonacute) PCIs being classified as inappropriate.…”

Hospital Performance on Percutaneous Coronary Intervention Process and Outcomes Measures

“…For the documentation of indications for PCI process measure, we classified a procedure as correctly documented based on recommendations from the PCPI, which included the following: documentation of priority of diagnoses (acute coronary syndrome vs elective); presence and severity of angina symptoms; use of antianginal medical therapies within 2 weeks before the procedure; significance of angiographic stenosis on coronary angiography for treated lesion; and presence, results, and timing of noninvasive stress test, fractional flow reserve, or intravascular ultrasound. For the measure of the proportion of elective PCIs considered appropriate, we defined it in a manner consistent with the PCPI guidelines, which is the sum of the total number of appropriate and uncertain cases (as opposed to inappropriate or unmappable) among all non‐acute coronary syndrome PCIs defined in a manner consistent with 2012 appropriate usage criteria 14. Finally, we created composite measures defined as the total number of process measures patients received over the total number of eligible performance measures for patients treated at that hospital.…”

Cardiac magnetic resonance imaging derived quantification of myocardial ischemia and scar improves risk stratification and patient management in stable coronary artery disease

“…Therefore, the need to reach consensus concerning the assessment and reporting of ischemia has been identified [7]. Moreover, the presence of moderate to severe ischemia is a mandatory appropriateness criterion for percutaneous coronary intervention (PCI) in stable CAD [8]. Cardiac magnetic resonance imaging (CMR) is an established non-invasive method for the diagnosis of CAD [9].…”