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APPROPRIATE USE CRITERIA
ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate Use
Criteria for Coronary Revascularization inPatients With Acute
Coronary Syndromes
A Report of the American College of Cardiology Appropriate Use
Criteria Task Force, AmericanAssociation for Thoracic Surgery,
American Heart Association, American Society of
Echocardiography,American Society of Nuclear Cardiology, Society
for Cardiovascular Angiography and Interventions,Society of
Cardiovascular Computed Tomography, and the Society of Thoracic
Surgeons
CoronaryRevascularizationWriting Group
Manesh R. Patel, MD, FACC, FAHA, FSCAI, Cha
John H. Calhoon, MD
ir
Gregory J. Dehmer, MD, MACC, MSCAI, FACP, FAHA*James Aaron
Grantham, MD, FACCThomas M. Maddox, MD, MSC, FACC, FAHA
This document was approved by the American College of Cardiology
Boa
The American College of Cardiology requests that this document
be cited
Maron DJ, Smith PK. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016
appr
coronary syndromes: a report of the American College of
Cardiology Appro
American Heart Association, American Society of
Echocardiography, Americ
and Interventions, Society of Cardiovascular Computed
Tomography, and th
This document has been reprinted in Catheterization and
Cardiovascular
Copies: This document is available on the World Wide Web site of
the Am
please contact Elsevier Reprint Department, fax (212) 633-3820
or e-mail rep
Permissions: Multiple copies, modification, alteration,
enhancement, and
permission of the American College of Cardiology. Please contact
healthper
David J. Maron, MD, FACC, FAHAPeter K. Smith, MD, FACCy
*Society for Cardiovascular Angiography and Interventions
Representative. ySociety of Thoracic Surgeons
Representative.
Rating Panel
Michael J. Wolk, MD, MACC, Moderator
Manesh R. Patel, MD, FACC, FAHA, FSCAI,Writing Group
LiaisonGregory J. Dehmer, MD, MACC, MSCAI, FACP, FAHA,Writing Group
Liaison*Peter K. Smith, MD, FACC, Writing Group Liaison
James C. Blankenship, MD, MACCz
Alfred A. Bove, MD, PHD, MACCzSteven M. Bradley, MDxLarry S.
Dean, MD, FACC, FSCAI*Peter L. Duffy, MD, FACC, FSCAI*T. Bruce
Ferguson, JR, MD, FACCzFrederick L. Grover, MD, FACCzRobert A.
Guyton, MD, FACCk
Mark A. Hlatky, MD, FACCzHarold L. Lazar, MD, FACC{Vera H.
Rigolin, MD, FACCzGeoffrey A. Rose, MD, FACC, FASE#Richard J.
Shemin, MD, FACCkJacqueline E. Tamis-Holland, MD, FACCzCarl L.
Tommaso, MD, FACC, FSCAI*L. Samuel Wann, MD, MACC**John B. Wong,
MDz
zAmerican College of Cardiology Representative. xAmerican
HeartAssociation Representative. kSociety of Thoracic Surgeons
Representative.{American Association for Thoracic Surgery
Representative. #AmericanSociety of Echocardiography
Representative. **American Society of
Nuclear Cardiology Representative.
rd of Trustees in October 2016.
as follows: Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox
TM,
opriate use criteria for coronary revascularization in patients
with acute
priate Use Criteria Task Force, American Association for
Thoracic Surgery,
an Society of Nuclear Cardiology, Society for Cardiovascular
Angiography
e Society of Thoracic Surgeons. J Am Coll Cardiol
2016;XX:xxx–xx.
Interventions and the Journal of Nuclear Cardiology.
erican College of Cardiology (www.acc.org). For copies of this
document,
[email protected].
/or distribution of this document are not permitted without the
express
[email protected].
http://www.acc.orgmailto:[email protected]:[email protected]://dx.doi.org/10.1016/j.jacc.2016.10.034
-
Patel et al. J A C C V O L . - , N O . - , 2 0 1 6
AUC for Coronary Revascularization in Patients With ACS - , 2 0
1 6 :- –-2
Appropriate UseCriteria TaskForce
Gregory J. Dehmer, MD, MACC, Co-Chair
John U. Doherty, MD, FACC, Co-Chair
Steven R. Bailey, MD, FACC, FSCAI, FAHANicole M. Bhave, MD,
FACCAlan S. Brown, MD, FACCyyStacie L. Daugherty, MD, FACCMilind Y.
Desai, MBBS, FACCClaire S. Duvernoy, MD, FACCLinda D. Gillam, MD,
FACCRobert C. Hendel, MD, FACC, FAHAyyChristopher M. Kramer, MD,
FACC, FAHAzzBruce D. Lindsay, MD, FACCyy
Warren J. Manning, MD, FACCManesh R. Patel, MD, FACC, FAHAxxRitu
Sachdeva, MBBS, FACCL. Samuel Wann, MD, MACCyyDavid E. Winchester,
MD, FACCMichael J. Wolk, MD, MACCyyJoseph M. Allen, MA
yyFormer Task Force member, current member during the
writingeffort. zzFormer Task Force Co-Chair, current Co-Chair
during thewriting effort. xxFormer Task Force Chair, current Chair
during thewriting effort.
TABLE OF CONTENTS
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . -
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . -
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . -
2. METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . -
Indication Development . . . . . . . . . . . . . . . . . . . . .
. . . . -
Scope of Indications . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . -
3. ASSUMPTIONS . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . -
General Assumptions . . . . . . . . . . . . . . . . . . . . . .
. . . . . . -
4. DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . -
Indication . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . -
Cardiac Risk Factor Modification and AntianginalMedical Therapy
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
-
Culprit Stenosis . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . -
Symptoms of Myocardial Ischemia . . . . . . . . . . . . . . . .
. -
Unstable Angina . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . -
Stress Testing and Risk of Findings on NoninvasiveTesting . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . -
The Role of Patient Preference in the AUC . . . . . . . . . .
-
Specific Acute Coronary Syndromes . . . . . . . . . . . . . . .
. -
5. ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . -
6. CORONARY REVASCULARIZATION IN PATIENTS
WITH ACS: AUC (BY INDICATION) . . . . . . . . . . . . . . .
-
Table 1.1 STEMI – Immediate Revascularization byPCI . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . -
Table 1.2 STEMI – Initial Treatment by FibrinolyticTherapy . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. -
Table 1.3 STEMI – Revascularization of NonculpritArtery During
the Initial Hospitalization . . . . . . . . . . . . -
Table 1.4 NSTEMI/Unstable Angina . . . . . . . . . . . . . . . .
-
7. DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . -
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . -
APPENDIX A
Appropriate Use Criteria for CoronaryRevascularization in
Patients With Acute CoronarySyndromes: Participants . . . . . . . .
. . . . . . . . . . . . . . . . . -
APPENDIX B
Relationships With Industry and Other Entities . . . . . . -
ABSTRACT
The American College of Cardiology, Society for Cardiovas-cular
Angiography and Interventions, Society of ThoracicSurgeons, and
American Association for Thoracic Surgery,along with key specialty
and subspecialty societies, havecompleted a 2-part revision of the
appropriate use criteria(AUC) for coronary revascularization. In
prior coronaryrevascularization AUC documents, indications for
revascu-larization in acute coronary syndromes (ACS) and
stableischemic heart disease were combined into 1 document.
Toaddress the expanding clinical indications for
coronaryrevascularization, and in an effort to align the
subjectmatterwith the most current American College of
Cardiology/American Heart Association guidelines, the new AUC
forcoronary artery revascularization were separated into 2documents
addressing ACS and stable ischemic heart dis-ease individually.
This document presents the AUC for ACS.
Clinical scenarios were developed to mimic patientpresentations
encountered in everyday practice and
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J A C C V O L . - , N O . - , 2 0 1 6 Patel et al.- , 2 0 1 6 :-
–- AUC for Coronary Revascularization in Patients With ACS
3
included information on symptom status, presence ofclinical
instability or ongoing ischemic symptoms, priorreperfusion therapy,
risk level as assessed by noninvasivetesting, fractional flow
reserve testing, and coronaryanatomy. This update provides a
reassessment of clinicalscenarios that the writing group felt to be
affected bysignificant changes in the medical literature or gaps
fromprior criteria. The methodology used in this update issimilar
to the initial document but employs the recentmodifications in the
methods for developing AUC, mostnotably, alterations in the
nomenclature for appropriateuse categorization.
A separate, independent rating panel scored theclinical
scenarios on a scale of 1 to 9. Scores of 7 to 9indicate that
revascularization is considered appropriatefor the clinical
scenario presented. Scores of 1 to 3indicate that revascularization
is considered rarelyappropriate for the clinical scenario, whereas
scores inthe mid-range (4 to 6) indicate that coronary
revascu-larization may be appropriate for the clinical
scenario.Seventeen clinical scenarios were developed by awriting
committee and scored by the rating panel: 10were identified as
appropriate, 6 as may be appropriate,and 1 as rarely
appropriate.
As seen with the prior coronary revascularization
AUC,revascularization in clinical scenarios with
ST-segmentelevation myocardial infarction and
non–ST-segmentelevation myocardial infarction were considered
appro-priate. Likewise, clinical scenarios with unstable anginaand
intermediate- or high-risk features were deemedappropriate.
Additionally, the management of nonculpritartery disease and the
timing of revascularization arenow also rated. The primary
objective of the AUC is toprovide a framework for the assessment of
practice pat-terns that will hopefully improve physician
decisionmaking.
PREFACE
The American College of Cardiology (ACC), in collabo-ration with
the Society for Cardiovascular Angiographyand Interventions,
Society for Thoracic Surgeons,American Association for Thoracic
Surgery, and othersocieties, developed and published the first
version ofthe appropriate use criteria (AUC) for coronary
revas-cularization in 2009, with the last update in 2012. TheAUC
are an effort to assist clinicians in the rational useof coronary
revascularization in common clinical sce-narios found in everyday
practice. The new AUC forcoronary revascularization was developed
as separatedocuments for acute coronary syndromes (ACS) andstable
ischemic heart disease (SIHD). This was done toaddress the
expanding clinical indications for coronaryrevascularization,
include new literature published since
the last update, and align the subject matter with
theACC/American Heart Association guidelines An addi-tional goal
was to address several of the shortcomingsof the initial document
that became evident as experi-ence with the use of the AUC
accumulated in clinicalpractice.
The publication of AUC reflects 1 of several ongoingefforts by
the ACC and its partners to assist clinicians whoare caring for
patients with cardiovascular diseases and insupport of high-quality
cardiovascular care. The ACC/American Heart Association clinical
practice guidelinesprovide a foundation for summarizing
evidence-basedcardiovascular care and, when evidence is lacking,
pro-vide expert consensus opinion that is approved in reviewby the
ACC and American Heart Association. However, inmany areas,
variability remains in the use of cardiovas-cular procedures,
raising questions of over- or under-use.The AUC provide a practical
standard upon which toassess and better understand variability.
We are grateful to the writing committee for thedevelopment of
the overall structure of the document andclinical scenarios and to
the rating panel, a professionalgroup with a wide range of skills
and insights, for theirthoughtful deliberation of the merits of
coronary revas-cularization for various clinical scenarios. We
would alsolike to thank the parent AUC Task Force and the ACC
staff,Joseph Allen, Leah White, and specifically Maria Velas-quez,
for their skilled support in the generation of thisdocument.
Manesh R. Patel, MD, FACCChair, Coronary Revascularization
Writing Group
Chair, Appropriate Use Criteria Task Force
Michael J. Wolk, MD, MACCModerator, Appropriate Use Criteria
Task Force
1. INTRODUCTION
In a continuing effort to provide information to
patients,physicians, and policy makers, the Appropriate Use
TaskForce approved this revision of the 2012 coronary
revas-cularization AUC (1). Since publication of the 2012
AUCdocument, new guidelines for ST-segment elevationmyocardial
infarction (STEMI) (2) and non–ST-segmentelevation myocardial
infarction (NSTEMI)/unstableangina (3) have been published with
additional focusedupdates of the SIHD guideline and a combined
focusedupdate of the percutaneous coronary intervention (PCI)and
STEMI guideline (4,5). New clinical trials have beenpublished
extending the knowledge and evidence aroundcoronary
revascularization, including trials that challengeearlier
recommendations about the timing of nonculpritvessel PCI in the
setting of STEMI (6–8). Additionalstudies related to coronary
artery bypass graft surgery,medical therapy, and diagnostic
technologies such as
-
FIGURE 1 AUC Development Process
Indi
catio
n D
evel
opm
ent
App
ropr
iate
ness
D
eter
min
atio
nV
alid
atio
n D
aD
eter
min
atio
nDevelop lissumption
Prow
AA
ist of indicns, and def
ospective with Clinic
% Use AppropriaAppropria
Appro
cations, finitions
R
I
Compariscal Record
that is te, May B
ate, Rarelyopriate
Review Paprovi
WritingIn
Rating PIndication
1st roun
Appro(7–9) Ap(4–6) M(1–3) Ra
son ds
e y
anel >30 mide feedba
g Group Rndications
Panel Ratens in Two R
d – No Int
opriate Usppropriateay Be Apparely Appr
members ack
Revises
es the Rounds
teraction
se Score epropriate ropriate
LiteraturGuidelin
ProD
Increa
re Review ne Mappin
spective CDecision A
se Approp
and ng
Clinical Aids
priate Use
AUC ¼ appropriate use criteria.
Patel et al. J A C C V O L . - , N O . - , 2 0 1 6
AUC for Coronary Revascularization in Patients With ACS - , 2 0
1 6 :- –-4
fractional flow reserve (FFR) have emerged as well asanalyses
from The National Cardiovascular Data Registry(NCDR) on the
existing AUC that provide insights intopractice patterns, clinical
scenarios, and patient featuresnot previously addressed (9–11).
In an effort to make the AUC usable, meaningful, and
asup-to-date as possible, the writing group was asked todevelop AUC
specifically for coronary revascularization inACS including STEMI
to coincide with the recently pub-lished focused update of the
STEMI guidelines (5). A newseparate AUC document specific to SIHD
is under prepa-ration and will be forthcoming. The goal of the
writinggroup was to develop clinical indications (scenarios)
thatreflect typical situations encountered in everyday prac-tice,
which are then classified by a separate rating panel
using methodology previously described in detail (12)(Figure 1).
In addition, step-by-step flow charts are pro-vided to help use the
criteria.
2. METHODS
Indication Development
A multidisciplinary writing group consisting of cardio-vascular
health outcomes researchers, interventionalcardiologists,
cardiothoracic surgeons, and general car-diologists was convened to
review and revise the coro-nary revascularization AUC.
The revascularization AUC are on the basis of our cur-rent
understanding of procedure outcomes plus the po-tential patient
benefits and risks of the revascularization
-
Sco
Sco
Sco
J A C C V O L . - , N O . - , 2 0 1 6 Patel et al.- , 2 0 1 6 :-
–- AUC for Coronary Revascularization in Patients With ACS
5
strategies examined. The AUC are developed to identifymany of
the common clinical scenarios encountered inpractice, but cannot
possibly include every conceivablepatient presentation. (In this
document, the phrase“clinical scenario” is frequently used
interchangeablywith the term “indication.”) Some patients seen in
clinicalpractice are not represented in these AUC or have
addi-tional extenuating features that would alter the
appro-priateness of treatment compared with the exact
clinicalscenarios presented.
AUC documents often contain more detailed clinicalscenarios than
the more generalized situations covered inclinical practice
guidelines, and thus, subtle differencesbetween these documents may
exist. Furthermore,because recommendations for revascularization or
themedical management of coronary artery disease (CAD) arefound
throughout several clinical practice guidelines, theAUC ratings
herein are meant to unify related clinicalpractice guidelines and
other data sources and provide auseful tool for clinicians. The AUC
were developed withthe intent to assist patients and clinicians,
but are notintended to diminish the acknowledged complexity
oruncertainty of clinical decision-making and should not bea
substitute for sound clinical judgment. There areacknowledged
evidence gaps in many areas where clinicaljudgement and experience
must be blended with patientpreferences, and the existing knowledge
base must bedefined in clinical practice guidelines.
It is important to emphasize that a rating of appro-priate care
does not mandate that a procedure orrevascularization strategy be
performed, may be appro-priate care represents reasonable care and
can beconsidered by the patient and provider, and finally, arating
of rarely appropriate care should not prevent atherapy from being
performed. It is anticipated thatthere will be some clinical
scenarios rated as rarelyappropriate where an alternative therapy
or performingrevascularization may still be in the best interest of
aparticular patient. Situations where the clinician believesa
therapy contrary to the AUC rating is best for the pa-tient may
require careful documentation as to the spe-cific patient features
not captured in the clinical scenarioor the rationale for the
chosen therapy. Depending onthe urgency of care, obtaining a second
opinion may behelpful in some of these settings.
The AUC can be used in several ways. As a clinical tool,the AUC
assist clinicians in evaluating possible therapiesunder
consideration and can help better inform patientsabout their
therapeutic options. As an administrative andresearch tool, the AUC
provide a means to compare utili-zation patterns across a large
subset of providers todeliver an assessment of an individual
clinician’s man-agement strategies with those of similar
physicians. It isimportant to again emphasize that the AUC should
be
used to measure overall patterns of clinical care ratherthan to
adjudicate the appropriateness of individualcases. The ACC and its
collaborators believe that anongoing review of one’s practice using
these criteria willhelp guide more effective, efficient, and
equitable allo-cation of healthcare resources, and ultimately lead
tobetter patient outcomes. Under no circumstances shouldthe AUC be
used as the sole means to adjudicate ordetermine payment for
individual patients—rather, theintent of the AUC is to provide a
framework to evaluateoverall clinical practice and to improve the
quality of care.
In developing these AUC for coronary revasculariza-tion, the
rating panel was asked to rate each indicationusing the following
definition of appropriate use:
A coronary revascularization or antianginal thera-peutic
strategy is appropriate care when the potential
benefits, in terms of survival or health outcomes(symptoms,
functional status, and/or quality of life)exceed the potential
negative consequences of the
treatment strategy.
Although antianginal therapy is mentioned in thisdefinition, the
writing committee acknowledges that thefocus of this document is
revascularization, as it is thedominant therapy for patients with
ACS. Medical therapymay have a role in the management of ongoing
ischemicsymptoms, but not to the extent that it does for SIHD.
The rating panel scored each indication on a scale from1 to 9 as
follows:
re 7 to 9: Appropriate care
re 4 to 6: May be appropriate care
re 1 to 3: Rarely appropriate care
Appropriate Use Definition and Ratings
In rating these criteria, the rating panel was asked toassess
whether the use of revascularization for eachindication is
“appropriate care,” “may be appropriatecare,” or “rarely
appropriate care” using the followingdefinitions and their
associated numeric ranges.
Median Score 7 to 9: Appropriate Care
An appropriate option for management of patients in
thispopulation due to benefits generally outweighing risks;an
effective option for individual care plans, although notalways
necessary depending on physician judgment andpatient-specific
preferences (i.e., procedure is generallyacceptable and is
generally reasonable for the indication).
Median Score 4 to 6: May Be Appropriate Care
At times, an appropriate option for management of pa-tients in
this population due to variable evidence oragreement regarding the
risk-benefit ratio, potential
-
Patel et al. J A C C V O L . - , N O . - , 2 0 1 6
AUC for Coronary Revascularization in Patients With ACS - , 2 0
1 6 :- –-6
benefit on the basis of practice experience in theabsence of
evidence, and/or variability in the popula-tion; effectiveness for
individual care must be deter-mined by a patient’s physician in
consultation with thepatient on the basis of additional clinical
variables andjudgment along with patient preferences (i.e.,
proceduremay be acceptable and may be reasonable for
theindication).
Median Score 1 to 3: Rarely Appropriate Care
Rarely an appropriate option for management of patientsin this
population due to the lack of a clear benefit/riskadvantage;
rarely, an effective option for individual careplans; exceptions
should have documentation of theclinical reasons for proceeding
with this care option (i.e.,procedure is not generally acceptable
and is not generallyreasonable for the indication).
Scope of Indications
The indications for coronary revascularization in ACS
weredeveloped considering the following common variables:
1. The clinical presentation (STEMI, NSTEMI, or other ACS);2.
Time from onset of symptoms;3. Presence of other complicating
factors (severe heart
failure or cardiogenic shock; hemodynamic or elec-trical
instability, presence of left ventricular dysfunc-tion, persistent
or recurring ischemic symptoms);
4. Prior treatment by fibrinolysis;5. Predicted risk as
estimated by the Thrombolysis In
Myocardial Infarction score;6. Relevant comorbidities; and7.
Extent of anatomic disease in the culprit and non-
culprit arteries.
The writing group characterized ACS and their man-agement into
the 2 common clinical presentations: STEMIand NSTEMI/unstable
angina. The anatomic construct forCAD is on the basis of the
presence or absence of impor-tant obstructions in the coronary
arteries categorized bythe number of vessels involved 1-, 2-, and
3-vessel CAD)and the ability to identify the culprit artery
responsiblefor the ACS Although the culprit stenosis is
frequentlyobvious from the coronary angiogram, there are
situationswhere the location of the culprit stenosis is uncertain
orwhere multiple culprit stenoses may exist.
After initial treatment of the patient with an ACS, itmay be
helpful to categorize the amount of myocardiumat risk or affected
by ischemia; thus, a minority of sce-narios include noninvasive
testing. The writing groupcharacterized noninvasive test findings
as low-risk versusintermediate- or high-risk, as these terms are
routinelyused in clinical practice. The use of FFR measurement
isincreasing in the setting of stable ischemic heart disease,but
there are limited data on its utility in the setting of
ACS to evaluate nonculprit vessels (6). Nevertheless, thewriting
group provided some indications with invasivephysiology testing
(represented by FFR) in nonculpritvessels in patients with ACS.
3. ASSUMPTIONS
General Assumptions
Specific instructions and assumptions used by the ratingpanel to
assist in the rating of clinical scenarios are listedin the
following text:
1. Each clinical scenario is intended to provide the
keyinformation typically available when a patient pre-sents with an
ACS, recognizing that especially in thesetting of an STEMI, the
need for rapid treatment mayprevent a complete evaluation.
2. Although the clinical scenarios should be rated on thebasis
of the published literature, the writing commit-tee acknowledges
that in daily practice, decisionsabout therapy are required in
certain patient pop-ulations that are poorly represented in the
literature.Therefore, rating panel members were instructed touse
their best clinical judgment and experience inassigning ratings to
clinical scenarios that have lowlevels of evidence.
3. In ACS, the percent luminal diameter narrowing of astenosis
may be difficult to assess. Determining thesignificance of a
stenosis includes not only thepercent luminal diameter narrowing,
but also theangiographic appearance of the stenosis and distalflow
pattern. For these clinical scenarios, a coronarystenosis in an
artery is defined as:
n Severe:a. A $70% luminal diameter narrowing of an
epicardial stenosis made by visual assessmentin the “worst view”
angiographic projection; or
b. A $50% luminal diameter narrowing of the leftmain artery made
by visual assessment, in the“worst view” angiographic
projection.
n Intermediate:c. A $50% and
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J A C C V O L . - , N O . - , 2 0 1 6 Patel et al.- , 2 0 1 6 :-
–- AUC for Coronary Revascularization in Patients With ACS
7
6. Revascularization by either percutaneous or surgicalmethods
is performed in a manner consistent withestablished standards of
care at centers with quality/volume standards (18–20).
7. No unusual extenuating circumstances exist in theclinical
scenarios such as but not limited to do-not-resuscitate status,
advanced malignancy, unwilling-ness to consider revascularization,
technical reasonsrendering revascularization infeasible, or
comorbid-ities likely to markedly increase procedural risk.
8. Assume that the appropriateness rating applies onlyto the
specific treatment strategy outlined in thescenario and not
additional revascularization pro-cedures that may be performed
later in the patient’scourse. Specifically, additional elective
revasculari-zation procedures (so called delayed staged
proced-ures) performed after the hospitalization for ACS
areevaluated and rated in the forthcoming AUC docu-ment on SIHD.
For data collection purposes, this willrequire documenting that the
procedure is staged(either PCI or hybrid revascularization with
surgery).
9. As with all previously published clinical policies,
de-viations by the rating panel from prior publisheddocuments were
driven by new evidence and/orimplementation of knowledge that
justifies suchevolution. However, the reader is advised to
paycareful attention to the wording of an indication in thepresent
document and should avoid making compar-isons to prior
documents.
10. Indication ratings contained herein supersede theratings of
similar indications contained in previousAUC coronary
revascularization documents.
4. DEFINITIONS
Definitions of terms used throughout the indication setare
listed here. These definitions were provided to anddiscussed with
the rating panel before the rating of in-dications. The writing
group assumed that noninvasiveassessments of coronary anatomy
(i.e., cardiac computedtomography, cardiac magnetic resonance
angiography)provide anatomic information that is potentially
similarto X-ray angiography. However, these modalities do
notcurrently provide information on ischemic burden and arenot
assumed to be present in the clinical scenarios.
Indication
A set of patient-specific conditions defines an “indica-tion,”
which is used interchangeably with the phrase“clinical
scenario.”
Cardiac Risk Factor Modification andAntianginal Medical
Therapy
The indications assume that patients are
receivingguideline-directed medical therapies for their ACS
including antiplatelet and anticoagulant
medications,beta-blockers, statins, and other medications as
indicatedby their clinical condition.
Culprit Stenosis
The phrase “culprit stenosis” is often used interchange-ably
with “infarct-related artery” to identify the coronaryartery
stenosis and/or artery responsible for the ACS. Inthis document,
the phrase “culprit stenosis or culprit ar-tery” is preferred,
because in the setting of unstable anginathere may be a culprit
stenosis or culprit artery, but bydefinition, there is no evidence
of a myocardial infarction.
Symptoms of Myocardial Ischemia
For the purposes of the clinical scenarios in this docu-ment,
the AUC are intended to apply to patients who havethe typical
underlying pathology of an ACS, not simply anelevated troponin
value in the absence of an appropriateclinical syndrome. The
symptoms of an ACS may bedescribed as both typical and atypical
angina or symp-toms felt to represent myocardial ischemia, such as
ex-ertional dyspnea, and are captured under the broad term“ischemic
symptoms.” Although previous AUC had usedthe Canadian
Cardiovascular Society system for anginalclassification, the
writing group recognized that the broadspectrum of ischemic
symptoms may limit patients’functional status in a variety of ways,
and capturing theCanadian Cardiovascular Society status in clinical
practicemay also vary widely. Therefore, the presence or absenceof
ischemic symptoms are presented without specificscale.
Additionally, post–ACS symptoms may persist and/or be easily
provoked with minimal activity.
Unstable Angina
The definition of unstable angina is largely on the basis ofthe
clinical presentation. Unstable angina is defined astypical chest
pain or other ischemic symptoms occurringat rest or with minimal
exertion, and presumed to berelated to an acutely active coronary
plaque. In contrastto stable angina, unstable angina is often
described assevere and as a frank pain. Moreover, unstable
anginamay be new in onset or occur in a crescendo pattern in
apatient with a previous stable pattern of angina. Unstableangina
may be associated with new electrocardiographicchanges such as
transient ST-segment elevation, ST-segment depression, or T-wave
inversion, but may bepresent in the absence of electrocardiographic
changes.Several scoring systems exist for determining
high-riskpatients with ACS (Tables A and B).
Stress Testing and Risk of Findings on Noninvasive Testing
Stress testing and coronary CTA are commonly used forboth
diagnosis and risk stratification of patients with cor-onary artery
disease or those with suspected ACS.
-
TABLE AHigh-Risk Features for Short-Term Risk ofDeath or
Nonfatal MI in Patients WithNSTEMI/UA
At least 1 of the following:n History—accelerating tempo of
anginal symptoms in preceding 48 hoursn Character of pain—prolonged
ongoing (>20 minutes) rest painn Clinical findings
n Pulmonary edema, most likely due to ischemian New or worsening
MR murmurn S3 or new/worsening ralesn Hypotension, bradycardia,
tachycardian Age >75 years
n ECGn Transient ST-segment deviation >0.5 mmn Bundle-branch
block, new or presumed newn Sustained ventricular tachycardia
n Cardiac markern Elevated cardiac TnT, TnI, or CK-MB (e.g., TnT
or TnI >0.1 ng per ml)
High-risk features were defined as in the ACS guidelines
(21).
CK-MB ¼ creatine kinase, MB isoenzyme; ECG ¼ electrocardiogram;
MI ¼ myocardialinfarction; MR ¼ mitral regurgitation; NSTEMI ¼
non–ST segment elevation myocardialinfarction; TnI ¼ troponin I;
TnT ¼ troponin T; UA ¼ unstable angina.
Patel et al. J A C C V O L . - , N O . - , 2 0 1 6
AUC for Coronary Revascularization in Patients With ACS - , 2 0
1 6 :- –-8
Although often contraindicated in ACS, stress testing maybe
performed for further risk stratification later during theindex
hospitalization. Risk stratification by noninvasivetesting is
defined as (4):
Lo
Int
Hig
TABL
Variablen Agen $3 rn Known Aspin Seven ST-sn Elev
Risk of dn Lown Inten High
ACS ¼ alitus; FH
w-risk stress test findings: associated with a 3%per year
cardiac mortality rate.
The Role of Patient Preference in the AUC
Patients often make decisions about medical treatmentswithout a
complete understanding of their options. Pa-tient participation or
shared decision-making describes acollaborative approach where
patients are providedevidence-based information on treatment
choices and areencouraged to use the information in an informed
dia-logue with their provider to make decisions that not onlyuse
the scientific evidence, but also align with theirvalues,
preferences, and lifestyle (23–25). The alternative
E BThrombolysis In Myocardial Infarction RiskScore—For Patients
With Suspected ACS (22)
s (1 point each)$65 yearsisk factors (HTN, DM, FH, lipids,
smoking)n CAD (stenosis $50%)
rin use in past 7 daysre angina ($2 episodes within 24
hours)egment deviation $0.5 mmated cardiac markers
eath or ischemic event through 14 days: 0–2 (70% diameter
stenosis in 1 angiographic plane or >50%in 2 planes and in an
artery >2 mm suitable for stentimplantation. Treatment of the
nonculprit stenosis
-
ACS ¼AUC ¼CAD ¼FFR ¼NSTEM
PCI ¼SIHD
STEM
TABLE C Treatment of Nonculprit Stenoses in the Patient With
STEMI
PRAMI(n ¼ 465)
CvLPRIT(n ¼ 296)
DANAMI3-PRIMULTI(n ¼ 627)
Randomization After primary PCI “During” primary PCI After
primary PCI
Lesion criteria >50% DS >70% DS or >50% DS in 2 views
>50% DS and FFR 90% DS
Strategy for non–IRA lesions Immediate—at time of primary PCI
Immediate or staged within index admission Staged within index
admission (average day 2)
CvLPRIT ¼ Complete Versus Lesion-Only Primary PCI Trial;
DANAMI3-PRIMULTI ¼ The Third Danish Study of Optimal Acute
Treatment of Patients with STEMI: Primary PCI in Mul-tivessel
Disease; DS ¼ diameter stenosis; FFR ¼ fractional flow reserve; IRA
¼ infarct-related artery; PCI ¼ percutaneous coronary intervention;
PRAMI ¼ Preventive Angioplasty inAcute Myocardial Infarction
Trial.
J A C C V O L . - , N O . - , 2 0 1 6 Patel et al.- , 2 0 1 6 :-
–- AUC for Coronary Revascularization in Patients With ACS
9
immediately following the primary PCI was encouraged,but could
be deferred to later during the same hospitali-zation. In
DANAMI3-PRIMULTI (The Third Danish Study ofOptimal Acute Treatment
of Patients with STEMI: PrimaryPCI in Multivessel Disease),
nonculprit stenoses weretreated if the diameter stenosis was
>50% and theFFR 90%.Treatment of the nonculprit stenoses was
planned for 2days after the primary PCI during the index
hospitaliza-tion. These variations in the criteria for nonculprit
stenosistreatment and timing of treatment from these 3
relativelysmall studies make it challenging to develop clinical
sce-narios. This is an evolving shift in the treatment paradigmfor
patients presenting with STEMI that, at present, isincompletely
understood. Scenarios were developed toallow the rating panel to
evaluate clinical situations thatmirror the evidence provided in
these new trials.
This AUC only covers clinical scenarios where theculprit artery
and additional nonculprit arteries aretreated at the time of
primary PCI or later during theinitial hospitalization. The writing
group recognizes theremay be circumstances where treatment of a
nonculpritartery is deferred beyond the initial hospitalization.
Thatspecific circumstance was not studied in the 3 recent
trials
TABLE 1 .1 STEMI—Immediate Revascularization by PCI
Indication
Revascularization of the Presumed Culprit Artery by PCI (Primary
PCI)
1. n Less than or equal to 12 hours from onset of symptoms
2. n Onset of symptoms within the prior 12–24 hours ANDn Severe
HF, persistent ischemic symptoms, or hemodynamic or electri
3. n Onset of symptoms within the prior 12–24 hours ANDn Stable
without severe HF, persistent ischemic symptoms, or hemodyn
Successful Treatment of the Culprit Artery by Primary PCI
Followed by Immethe Same Procedure
4. n Cardiogenic shock persisting after PCI of the presumed
culprit arteryn PCI or CABG of 1 or more additional vessels
5. n Stable patient immediately following PCI of the presumed
culprit artn One or more additional severe stenoses
6. n Stable patient immediately following PCI of the presumed
culprit artn One or more additional intermediate (50%–70%)
stenoses
The number in parenthesis next to the rating reflects the median
score for that indication.
A ¼ appropriate; CABG ¼ coronary artery bypass graft; HF ¼ heart
failure; M ¼ may be apST-segment elevation myocardial
infarction.
of nonculprit stenosis treatment. However, if the
char-acteristics of the patient are such that treatment of
non-culprit stenoses are deferred beyond the
initialhospitalization, it is assumed the patient is
clinicallystable. These clinical scenarios will be evaluated in
theforthcoming SIHD document.
5. ABBREVIATIONS
cal insta
amic or
diate R
ery
ery
propriate
acute coronary syndrome
appropriate use criteria
coronary artery disease
fractional flow reserve
I ¼ non–ST-segment elevation myocardial infarctionpercutaneous
coronary intervention
¼ stable ischemic heart diseaseI ¼ ST-segment elevation
myocardial infarction
6. CORONARY REVASCULARIZATION IN
PATIENTS WITH ACS: AUC (BY INDICATION)
Scenarios 1 to 3 in Table 1.1 specifically address treatmentof
the culprit stenosis at the time intervals and with the
Appropriate Use Score (1–9)
A (9)
bility presentA (8)
electrical instabilityM (6)
evascularization of 1 or More Nonculprit Arteries During
A (8)
M (6)
M (4)
; PCI ¼ percutaneous coronary intervention; R ¼ rarely
appropriate; STEMI ¼
-
TABLE 1 .2 STEMI—Initial Treatment by Fibrinolytic Therapy
Indication Appropriate Use Score (1–9)
PCI of the Presumed Culprit Artery After Fibrinolysis
7. n Evidence of failed reperfusion after fibrinolysis (e.g.,
failure of ST-segment resolution, presence of acutesevere HF,
ongoing myocardial ischemia, or unstable ventricular
arrhythmias)
A (9)
8. n Stable after fibrinolysis ANDn Asymptomatic (no HF,
myocardial ischemia, or unstable ventricular arrhythmias) ANDn PCI
performed 3–24 hours after fibrinolytic therapy
A (7)
9. n Stable after fibrinolysis ANDn Asymptomatic (no HF,
myocardial ischemia, or unstable ventricular arrhythmias) ANDn PCI
>24 hours after onset of STEMI
M (5)
The number in parenthesis next to the rating reflects the median
score for that indication.
A ¼ appropriate; CABG ¼ coronary artery bypass graft; HF ¼ heart
failure; M ¼ may be appropriate; PCI ¼ percutaneous coronary
intervention; R ¼ rarely appropriate; STEMI ¼ST-segment elevation
myocardial infarction.
TABLE 1 .3 STEMI—Revascularization of Nonculprit Artery During
the Initial Hospitalization
Indication Appropriate Use Score (1–9)
Successful Treatment of the Culprit Artery by Primary PCI or
Fibrinolysis Revascularization of 1 or More Nonculprit Arteries
Duringthe Same Hospitalization
Revascularization by PCI or CABG
10. n Spontaneous or easily provoked symptoms of myocardial
ischemian One or more additional severe stenoses
A (8)
11. n Asymptomaticn Findings of ischemia on noninvasive testingn
One or more additional severe stenoses
A (7)
12. n Asymptomatic (no additional testing performed)n One or
more additional severe stenoses
M (6)
13 n Asymptomatic (no additional testing performed)n One or more
additional intermediate stenoses
R (3)
14. n Asymptomaticn One or more additional intermediate
(50%–70%) stenosesn FFR performed and #0.80
A (7)
The number in parenthesis next to the rating reflects the median
score for that indication.
A ¼ appropriate; CABG ¼ coronary artery bypass graft; FFR ¼
fractional flow reserve; M ¼ may be appropriate; PCI ¼ percutaneous
coronary intervention; R ¼ rarely appropriate;STEMI ¼ ST-segment
elevation myocardial infarction.
Patel et al. J A C C V O L . - , N O . - , 2 0 1 6
AUC for Coronary Revascularization in Patients With ACS - , 2 0
1 6 :- –-10
presence or absence of symptoms as noted. Scenarios 4 to6 in
Table 1.1 specifically address treatment of 1 or morenonculprit
stenoses during the same procedure as treat-ment of the culprit
stenosis. Because these scenarios arespecific for nonculprit
treatment immediately following
TABLE 1.4 NSTEMI/Unstable Angina
Indication
Revascularization by PCI or CABG
15. n Evidence of cardiogenic shockn Immediate revascularization
of 1 or more coronary arteries
16. n Patient stabilizedn Intermediate- OR high-risk features
for clinical events (e.g., TIMI scorn Revascularization of 1 or
more coronary arteries
17. n Patient stabilized after presentationn Low-risk features
for clinical events (e.g., TIMI score #2)n Revascularization of 1
or more coronary arteries
The number in parenthesis next to the rating reflects the median
score for that indication.
A ¼ appropriate; CABG ¼ coronary artery bypass graft; M ¼ may be
appropriate; NSTEintervention; R ¼ rarely appropriate; TIMI ¼
Thrombolysis In Myocardial Infarction.
primary PCI, the criteria for treatment used in DANAMI3-PRIMULTI
cannot be applied in this table.
As noted in Table 1.1, treatment of the nonculprit arterycan
occur at several different times after treatment of theculprit
stenosis. Because Table 1.1 covers those scenarios
Appropriate Use Score (1–9)
A (9)
e 3–4)A (7)
M (5)
MI ¼ non–ST-segment elevation myocardial infarction; PCI ¼
percutaneous coronary
-
J A C C V O L . - , N O . - , 2 0 1 6 Patel et al.- , 2 0 1 6 :-
–- AUC for Coronary Revascularization in Patients With ACS
11
where nonculprit treatment occurs immediately after theprimary
PCI, this table is specific for treatment of non-culprit stenoses
after the initial procedure, but during theinitial
hospitalization.
Unstable angina/NSTEMI category—in patients withThrombolysis In
Myocardial Infarction 3 flow and multi-ple coronary artery
stenoses, consideration should begiven for heart team evaluation in
patients with a highburden of CAD, such as 2-vessel disease with
proximal leftanterior descending coronary artery stenosis or more
se-vere disease.
7. DISCUSSION
The new AUC ratings for ACS are consistent with
existingguidelines for STEMI and NSTEMI-ACS (Figure 2). Forpatients
with ACS, revascularization by either PCI or
FIGURE 2 Flow Diagram for the Determination of Appropriate Use
in Patie
Asx ¼ asymptomatic; CABG ¼ coronary artery bypass graft; FFR ¼
fractional flomyocardial infarction; PCI ¼ percutaneous coronary
intervention; STEMI ¼ ST-s
CABG is the most commonly used therapy, and this isreflected in
the ratings of “appropriate care” or “may beappropriate care” for
all but 1 of the 17 scenarios pre-sented. Although these AUC
ratings do not compare themerits of PCI versus CABG for
revascularization in ACS, inclinical practice, patients presenting
with STEMI typicallyare treated by PCI of the culprit stenosis.
However, theoption of surgical revascularization should be
consideredfor patients with ACS but less acute presentation,
espe-cially in those with complex multivessel CAD.
The current AUC rate revascularization as “appropriatecare” for
patients presenting within 12 hours of the onsetof STEMI or up to
24 hours if there is clinical instability.For STEMI patients
presenting more than 12 and up to 24hours from symptom onset but
with no signs of clinicalinstability, revascularization was rated
as “may beappropriate,” indicating that many on the technical
panel
nts With Acute Coronary Syndromes
w reserve; HF ¼ heart failure; NSTEMI ¼ non–ST-segment
elevationegment elevation myocardial infarction; UA ¼ unstable
angina.
-
Patel et al. J A C C V O L . - , N O . - , 2 0 1 6
AUC for Coronary Revascularization in Patients With ACS - , 2 0
1 6 :- –-12
consider it reasonable to revascularize such
patients.Furthermore, nonculprit artery revascularization at
thetime of primary PCI was rated as “may be appropriate,”but
because this is an emerging concept on the basis ofrelatively small
studies, clinical judgment by the operatoris encouraged.
For STEMI patients initially treated with
fibrinolysis,revascularization was rated as “appropriate therapy”
inthe setting of suspected failed fibrinolytic therapy or instable
and asymptomatic patients from 3 to 24 hours afterfibrinolysis. In
the setting of suspected failed fibrinolysis,the need for
revascularization is usually immediate,whereas in stable patients
with apparent successfulfibrinolysis, revascularization can be
delayed for up to 24hours. For stable patients >24 hours after
fibrinolysis,revascularization was rated as “may be
appropriate.”Revascularization soon after apparent successful
fibrino-lysis is supported by data and guideline recommenda-tions
about the management of patients transferred fromcenters where PCI
is not available.
Nonculprit artery revascularization during the
indexhospitalization after primary PCI or fibrinolysis was
alsorated as appropriate and reasonable for patients with 1 ormore
severe stenoses and spontaneous or easily provokedischemia or for
asymptomatic patients with ischemicfindings on noninvasive testing.
In the presence of anintermediate-severity nonculprit artery
stenosis, revas-cularization was rated as “appropriate therapy”
providedthat the FFR was #0.80. For patients who are stable
andasymptomatic after primary PCI, revascularization wasrated as
“may be appropriate” for 1 or more severe ste-noses even in the
absence of further testing. The only“rarely appropriate” rating in
patients with ACS occurredfor asymptomatic patients with
intermediate-severitynonculprit artery stenoses in the absence of
any addi-tional testing to demonstrate the functional
significanceof the stenosis.
For patients with NSTEMI/unstable angina, andconsistent with
existing guidelines and the available
evidence, revascularization was rated as “appropriatecare” in
the setting of cardiogenic shock or in a patientwith intermediate-
or high-risk features. For stable pa-tients with low-risk features,
revascularization wasrated as “may be appropriate.” Decisions
around thetiming of revascularization, management of
multivesseldisease, and concomitant pharmacotherapy should allbe on
the basis of evidence from the relevant practiceguidelines.
In conclusion, the AUC for ACS are consistent withthe large body
of evidence and guideline recommenda-tions that support invasive
strategies to define anatomyand revascularize patients with STEMI
and NSTEMI-ACS. The evolving evidence around nonculprit
stenosisrevascularization has led to ratings that
revasculariza-tion may be appropriate after primary PCI in
selectedasymptomatic patients with severe stenoses, definedherein
as $70% diameter narrowing, or in patients
withintermediate-severity stenosis if FFR testing isabnormal. As in
prior versions of the AUC, theserevascularization ratings should be
used to reinforceexisting management strategies and identify
patientpopulations that need more information to identify themost
effective treatments.
ACC PRESIDENT AND STAFF
Richard A. Chazal, MD, FACC, PresidentShalom Jacobovitz, Chief
Executive OfficerWilliam J. Oetgen, MD, FACC, Executive Vice
President,
Science, Education, and QualityJoseph M. Allen, MA, Team Leader,
Clinical Policy and
PathwaysLeah White, MPH, CCRP, Team Leader, Appropriate Use
CriteriaMarίa Velásquez, Senior Research Specialist,
Appropriate
Use CriteriaAmelia Scholtz, PhD, Publications Manager,
Clinical
Policy and Pathways
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KEY WORDS ACC Appropriate Use Criteria,coronary
revascularization, imaging, medicaltherapy, multimodality
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Patel et al. J A C C V O L . - , N O . - , 2 0 1 6
AUC for Coronary Revascularization in Patients With ACS - , 2 0
1 6 :- –-14
APPENDIX A. APPROPRIATE USE CRITERIA FOR CORONARY
REVASCULARIZATION IN PATIENTS WITH
ACUTE CORONARY SYNDROMES: PARTICIPANTS
Writing Group
Manesh R. Patel, MD, FACC, FAHA, FSCAI—AssociateProfessor of
Medicine, Director Interventional Cardiologyand Catheterization
Labs, Duke University Health System,Duke Clinical Research
Institute, Durham, NC
John H. Calhoon, MD—Professor and Chair, PresidentsCouncil Chair
for Excellence in Surgery, Department ofCardiothoracic Surgery,
Director, University of TexasHealth Science Center at San Antonio,
Heart and VascularInstitute, San Antonio, TX
Gregory J. Dehmer, MD, MACC, MSCAI, FACP, FAHA—Clinical
Professor of Medicine, Texas A&M Health ScienceCenter College
of Medicine, Medical Director, Cardiovas-cular Services, Central
Texas Division, Director, Cardiol-ogy Division, Baylor Scott &
White–Temple Memorial,Temple, TX
James Aaron Grantham, MD, FACC—Associate ClinicalProfessor,
University of Missouri–Kansas City School ofMedicine, Director,
Cardiovascular Disease FellowshipProgram, University of
Missouri–Kansas City School ofMedicine, Director, Cardiovascular
Medical Education,Saint Luke’s Hospital, Kansas City, MO
Thomas M. Maddox, MD, MSc, FACC, FAHA—NationalDirector, VA CART
Program Cardiology, VA Eastern Col-orado Health Care System,
Associate Professor, Depart-ment of Medicine, Cardiology,
University of Colorado,Colorado Cardiovascular Outcomes Research
Consortium,Denver, CO
David J. Maron, MD, FACC, FAHA—Clinical Professor ofMedicine,
Cardiovascular, Director, Preventive Cardiol-ogy, ISCHEMIA Trial
Co-Chair, Principal Investigator,Stanford University School of
Medicine, Stanford, CA
Peter K. Smith, MD, FACC—Professor of Surgery, Divi-sion Chief,
Cardiovascular and Thoracic Surgery, DukeUniversity, Durham, NC
Rating Panel
Michael J. Wolk, MD, MACC, Moderator—Past President,American
College of Cardiology, Clinical Professor ofMedicine, Weill Medical
College of Cornell University,New York Cardiology Associates, New
York, NY
Manesh R. Patel, MD, FACC, FAHA, FSCAI, WritingCommittee
Liaison—Associate Professor of Medicine, Di-rector Interventional
Cardiology and CatheterizationLabs, Duke University Health System,
Duke ClinicalResearch Institute, Durham, NC
Gregory J. Dehmer, MD, MACC, MSCAI, FAHA, WritingCommittee
Liaison—Clinical Professor of Medicine, Texas
A&M Health Science Center College of Medicine,
MedicalDirector, Cardiovascular Services, Central Texas
Division,Director, Cardiology Division, Baylor Scott and
White,Temple Memorial, Temple, TX
Peter K. Smith, MD, FACC, Writing Committee Liaison—Professor of
Surgery, Division Chief, Cardiovascular andThoracic Surgery, Duke
University, Durham, NC
James C. Blankenship, MD, MACC—Staff Physician, Di-rector,
Cardiac Catheterization Laboratory, Division ofCardiology,
Geisinger Medical Center, Danville, PA
Alfred A. Bove, MD, PhD, MACC—Past President,American College of
Cardiology, Professor Emeritus,Lewis Katz School of Medicine, Heart
and Vascular,Temple University, Philadelphia, PA
Steven M. Bradley, MD—Staff Cardiologist, VA EasternColorado
Health Care System, Assistant Professor ofMedicine, Division of
Cardiology at the University ofColorado, Denver, CO
Larry S. Dean, MD, FACC, FSCAI—Professor of Medicineand Surgery,
University of Washington School of Medi-cine, Director, University
of Washington, MedicineRegional Heart Center, Seattle, WA
Peter L. Duffy, MD, FACC, FSCAI—Director of Qualityfor the
Cardiovascular Service Line, First Health of theCarolinas, Reid
Heart Institute/Moore Regional Hospital,Pinehurst, NC
T. Bruce Ferguson, Jr., MD, FACC—Professor ofThoracic Surgery,
Department of Cardiovascular Sciences,Cardiothoracic Surgery, East
Carolina Heart Institute, EastCarolina University, Greenville,
NC
Frederick L. Grover, MD, FACC—Professor of Cardio-thoracic
Surgery, Department of Cardiothoracic Surgery,University of
Colorado, Denver, CO
Robert A. Guyton, MD, FACC—Chief of CardiothoracicSurgery,
Professor of Surgery, Division of CardiothoracicSurgery, Department
of Surgery, Director, Thoracic Sur-gery Residency Program, Emory
University School ofMedicine, Atlanta, GA
Mark A. Hlatky, MD, FACC—Professor of HeathResearch and Policy,
Health Services Research, Professorof Medicine, Cardiovascular
Medicine, Stanford Univer-sity School of Medicine, Stanford, CA
Harold L. Lazar, MD, FACC—Director, CardiothoracicResearch
Program, Professor of Cardiothoracic Surgery,Boston University
School of Medicine, Boston, MA
Vera H. Rigolin, MD, FACC—Professor, Cardiology,Northwestern
University Feinberg School of Medicine,Chicago, IL
-
J A C C V O L . - , N O . - , 2 0 1 6 Patel et al.- , 2 0 1 6 :-
–- AUC for Coronary Revascularization in Patients With ACS
15
Geoffrey A. Rose, MD, FACC, FASE—Chief, Division ofCardiology,
Sanger Heart and Vascular Institute, Char-lotte, NC
Richard J. Shemin, MD, FACC—Robert and Kelly DayProfessor, Chief
of Cardiothoracic Surgery, Executive ViceChair of Surgery,
Co-Director of the Cardiovascular Cen-ter, Director of Cardiac
Quality at the Ronald ReaganUCLA Medical Center, Los Angeles,
CA
Jacqueline E. Tamis-Holland, MD, FACC—Director,Interventional
Cardiology Fellowship, Mount Sinai, SaintLuke’s Hospital Director,
Women’s Heart NY AssistantProfessor of Medicine, Icahn School of
Medicine at MountSinai Hospital, New York, NY
Carl L. Tommaso, MD, FACC, FSCAI—Director of theCardiac
Catheterization Laboratory at Skokie IllinoisHospital, part of the
Northshore University Health Sys-tem, Associate Professor of
Medicine at Rush MedicalCollege in Chicago, Chicago, IL
L. Samuel Wann, MD, MACC—Past President, AmericanCollege of
Cardiology, Clinical Cardiologist, Columbia St.Mary’s Healthcare,
Medical Director, Heart Failure Pro-gram, Milwaukee, WI
John B. Wong, MD—Chief, Division of Clinical DecisionMaking,
Primary Care Physician, Principal Investigator,Institute for
Clinical Research and Health Policy Studies,Professor, Tufts
University School ofMedicine, Boston, MA
Reviewers
Jeffrey L. Anderson, MD, FACC—Associate Chief of Car-diology,
Intermountain Medical Center, Murray, UT
James C. Blankenship, MD, MACC—Staff Physician, Di-rector,
Cardiac Catheterization Laboratory, GeisingerMedical Center,
Division of Cardiology, Danville, PA
Jeffrey A. Brinker, MD, FACC—Professor of Medicine,Johns Hopkins
Hospital, Baltimore, MD
Alexandru I. Costea, MD—Associate Professor, Univer-sity of
Cincinnati Medical Center, Cincinnati, OH
Ali E. Denktas, MD, FACC—Assistant Professor, BaylorCollege of
Medicine, Houston, TX
Lloyd W. Klein, MD, FACC—Professor of Medicine,Melrose Park,
IL
Frederick G. Kushner, MD, FACC—Clinical Professor,Tulane
University Medical Center, Medical Director, HeartClinic of
Louisiana, Marrero, LA
Glenn N. Levine, MD, FACC—Professor, Baylor Collegeof Medicine,
Cardiology, Pearland, TX
David Joel Maron, MD, FACC—Professor of Medicineand Emergency
Medicine, Stanford University School ofMedicine, Stanford, CA
James B. McClurken, MD, FACC—Director of ThoracicSurgery,
Professor of Surgery Emeritus, Temple Univer-sity, School of
Medicine, Richard A Reif Heart Institute,Doylestown Hospital,
Doylestown, PA
Robert N. Piana, MD, FACC—Professor of Medicine,Cardiology,
Vanderbilt University Medical Center, Nash-ville, TN
John A. Spertus, M.D, MPH, FACC—Adjunct Professor ofMedicine,
Washington University School of Medicine, St.Louis, MO
Raymond F. Stainback, MD, FACC—Medical Director,Non-Invasive
Cardiology Texas Heart Institute at BaylorSt. Luke’s Medical
Center, Houston, TX
Robert C. Stoler, MD, FACC—Director of Cardiac Cath-eterization
Laboratory, Cardiology Consultants of Texas,Dallas, TX
Todd C. Villines, MD, FACC—Co-Director of Cardiovas-cular
Computed Tomography and Assistant Chief, Cardi-ology Service at
Walter Reed Army Medical Center,Rockville, MD
David H. Wiener, MD, FACC—Professor of Medicine,Jefferson
Medical College, Jefferson Heart Institute,Philadelphia, PA
ACC Appropriate Use Criteria Task Force
John U. Doherty, MD, FACC, FAHA—Co-Chair, AUC TaskForce,
Professor of Medicine, Jefferson Medical College ofThomas Jefferson
University, Philadelphia, PA
Gregory J. Dehmer, MD, MACC—Co-Chair, AUC TaskForce, Medical
Director, Cardiovascular Services, CentralTexas Division, Baylor
Scott & White Health, Temple, TX
Steven R. Bailey, MD, FACC, FSCAI, FAHA—Chair, Di-vision of
Cardiology, Professor of Medicine and Radi-ology, Janey Briscoe
Distinguished Chair, University ofTexas Health Sciences Center, San
Antonio, TX
Nicole M. Bhave, MD, FACC—Clinical Assistant Profes-sor,
Department of Internal Medicine, Division of Car-diovascular
Medicine, University of MichiganCardiovascular Center, Ann Arbor,
MI
Alan S. Brown, MD, FACC—Medical Director, MidwestHeart Disease
Prevention Center, Advocate LutheranGeneral Hospital, Director,
Division of Cardiology, ParkRidge, IL
Stacie L. Daugherty, MD, FACC—Associate Professor,Division of
Cardiology, Department of Medicine, Univer-sity of Colorado School
of Medicine, Denver, CO
Milind Y. Desai, MBBS, FACC—Associate Director,Clinical
Investigations Heart and Vascular Institute,Cleveland Clinic,
Cleveland, OH
Claire S. Duvernoy, MD, FACC—Cardiology SectionChief, Division
of Cardiology, University of MichiganHealth System, Ann Arbor,
MI
Linda D. Gillam, MD, FACC—Chair, Department of Car-diovascular
Medicine, Morristown Medical Center, Mor-ristown, NJ
Robert C. Hendel, MD, FACC, FAHA—Director of Car-diac Imaging
and Outpatient Services, Division of Cardi-ology, Miami University
School of Medicine, Miami, FL
-
Patel et al. J A C C V O L . - , N O . - , 2 0 1 6
AUC for Coronary Revascularization in Patients With ACS - , 2 0
1 6 :- –-16
Christopher M. Kramer, MD, FACC, FAHA—FormerCo-Chair, AUC Task
Force, Ruth C. Heede Professor ofCardiology & Radiology, and
Director, CardiovascularImaging Center, University of Virginia
Health System,Charlottesville, VA
Bruce D. Lindsay, MD, FACC—Professor of Cardiology,Cleveland
Clinic Foundation of Cardiovascular Medicine,Cleveland, OH
Warren J. Manning, MD, FACC—Professor of Medicineand Radiology,
Beth Israel Deaconess Medical Center,Division of Cardiology,
Boston, MA
Manesh R. Patel, MD, FACC, FAHA—Former Chair,AUC Task Force,
Assistant Professor of Medicine, Division
of Cardiology, Duke University Medical Center, Durham,NC
Ritu Sachdeva, MBBS, FACC—Associate Professor, Divi-sion of
Pediatric Cardiology, Department of Pediatrics,Emory University
School of Medicine, Children’s HealthCare of Atlanta, SibleyHeart
Center Cardiology, Atlanta, GA
L. Samuel Wann, MD, MACC—Staff Cardiologist,Columbia St. Mary’s
Healthcare, Milwaukee, WI
David E. Winchester, MD, FACC—Assistant Professor ofMedicine,
University of Florida, Division of Cardiology,Gainesville, FL
Joseph M. Allen, MA—Team Leader, Clinical Policy
andPathways,AmericanCollegeofCardiology,Washington,DC
-
J A C C V O L . - , N O . - , 2 0 1 6 Patel et al.- , 2 0 1 6 :-
–- AUC for Coronary Revascularization in Patients With ACS
17
APPENDIX B. RELATIONSHIPS WITH INDUSTRY (RWI) AND OTHER
ENTITIES
The College and its partnering organizations rigorouslyavoid any
actual, perceived, or potential conflicts of in-terest that might
arise as a result of an outside relation-ship or personal interest
of a member of the rating panel.Specifically, all panelists are
asked to provide disclosurestatements of all relationships that
might be perceived asreal or potential conflicts of interest. These
statementswere reviewed by the Appropriate Use Criteria Task
Force,
Participant Employment ConsultantSpeakBure
Writing G
Manesh R. Patel(Chair)
Duke University HealthSystem, Duke ClinicalResearch
Institute—
Associate Professor ofMedicine, Director
Interventional Cardiologyand Catheterization Labs
None Non
John H. Calhoon University of Texas HealthScience Center at
SanAntonio Department ofCardiothoracic Surgery,Heart and
VascularInstitute Director—Professor and Chair,
Presidents Council Chairfor Excellence in Surgery
None Non
Gregory J.Dehmer
Baylor Scott & White-Temple Memorial, TexasA&M Health
ScienceCenter College of
Medicine, Central TexasDivision—Clinical Professor
of Medicine, MedicalDirector, Cardiovascular
Services, Director,Cardiology Division
None Non
James AaronGrantham
Saint Luke’s Hospital—Associate Clinical
Professor, University ofMissouri–Kansas CitySchool of
Medicine—
Director, CardiovascularDisease FellowshipProgram, Director,
Cardiovascular MedicalEducation
n AbbottVascular†
n Asahi-Intecc†n Boston
Scientific†n Bridgepoint
MedicalSystems†
n Medtronic†
Non
Thomas M.Maddox
VA Eastern ColoradoHealth Care System—National Director,
Associate Professor,Department of Medicine,Cardiology,
University of
Colorado, ColoradoCardiovascular OutcomesResearch Consortium
None Non
APPROPRIATE USE CRITERIA FOR CORONARY REVAS
CORONARY SYNDROMES: MEMBERS OF THE WRITING
AND AUC TASK FORCE—RELATIONSHIPS WITH INDUS
discussed with all members of the rating panel at the
face-to-face meeting, and updated and reviewed as necessary.The
following is a table of relevant disclosures by therating panel and
oversight working group members. Inaddition, to ensure complete
transparency, a full list ofdisclosure information—including
relationships notpertinent to this document—is available in the
OnlineAppendix.
ersau
Ownership/Partnership/Principal
PersonalResearch
Institutional,Organizational,
or OtherFinancialBenefit
ExpertWitness
roup
e None None None None
e None None None None
e None None None None
e None n Abbott Vascular†n Asahi-Intecc†n Boston
Scientific†n Bridgepoint
MedicalSystems†
n Medtronic†
None None
e None None None None
Continued on the next page
CULARIZATION IN PATIENTS WITH ACUTE
GROUP, RATING PANEL, INDICATION REVIEWERS,
TRY AND OTHER ENTITIES (RELEVANT)
http://jaccjacc.acc.org/Clinical_Document/AUC_for_Coronary_Revasc_in%20Patients_with%20ACS_-_Comprehensive_RWI.docxhttp://jaccjacc.acc.org/Clinical_Document/AUC_for_Coronary_Revasc_in%20Patients_with%20ACS_-_Comprehensive_RWI.docx
-
Participant Employment ConsultantSpeakersBureau
Ownership/Partnership/Principal
PersonalResearch
Institutional,Organizational,
or OtherFinancialBenefit
ExpertWitness
David J. Maron Stanford University Schoolof
Medicine—ClinicalProfessor of Medicine,Cardiovascular,
Director,Preventive Cardiology
None None None None None None
Peter K. Smith Cardiovascular andThoracic Surgery,
DukeUniversity—Professor ofSurgery, Division Chief
None None None None None None
Rating Panel
James C.Blankenship
Geisinger Medical Center,Division of Cardiology—Staff Physician,
Director,Cardiac Catheterization
Laboratory
None None None n Abbott Vascular*n AstraZeneca*n Boston
Scientific*n GlaxoSmithKline*n Hamilton Health
Services*n Medinol LTD*n Orexigen Thera-
peutics/Takeda*n Stentys, Inc.*n Takeda
Pharmaceuticals
None None
Alfred A. Bove Temple University, LewisKatz School of
Medicine,Heart and Vascular—Professor Emeritus
None None None n Merck Schering-Plough†
None None
Steven M.Bradley
VA Eastern ColoradoHealth Care System,
Division of Cardiology atthe University ofColorado—Staff
Cardiologist, AssistantProfessor of Medicine
None None None None None None
Larry S. Dean Medicine Regional HeartCenter University
ofWashington School ofMedicine—Professor ofMedicine and
Surgery,
Director
n Philips Medical† None None n EdwardsLifesciences†
None None
Peter L. Duffy First Health of theCarolinas, Reid Heart
Institute/Moore RegionalHospital—Director of
Quality for theCardiovascular Service Line
None n Vol-canoCorp†
None None None None
T. BruceFerguson, Jr.
East Carolina HeartInstitute, East Carolina
University, Department ofCardiovascular Sciences,Cardiothoracic
Surgery—Professor of Thoracic
Surgery
None None n RFPi* n NovadaqTechnologies†
None None
Frederick L.Grover
University of Colorado,Department of
Cardiothoracic Surgery—Professor of
Cardiothoracic Surgery
n Somalution None None None None None
Robert A.Guyton
Emory University Schoolof Medicine, Division ofCardiothoracic
Surgery,Department of Surgery,
Thoracic SurgeryResidency Program—Chiefof Cardiothoracic
Surgery,
Professor of Surgery,Director
n Medtronic† None None None None None
Continued on the next page
APPENDIX B. CONTINUED
Patel et al. J A C C V O L . - , N O . - , 2 0 1 6
AUC for Coronary Revascularization in Patients With ACS - , 2 0
1 6 :- –-18
-
Participant Employment ConsultantSpeakersBureau
Ownership/Partnership/Principal
PersonalResearch
Institutional,Organizational,
or OtherFinancialBenefit
ExpertWitness
Mark A. Hlatky Stanford University Schoolof Medicine,
Cardiovascular Medicine,Health Services Research—
Professor of HeathResearch and Policy,Professor of Medicine
None None None n Sanofi-Aventis
None
Harold L. Lazar Boston University Schoolof Medicine,
Cardiothoracic ResearchProgram—Director
Professor ofCardiothoracic Surgery
None None None None None None
Vera H. Rigolin Northwestern UniversityFeinberg School of
Medicine, Cardiology—Professor
None None None None n Pfizer† None
Geoffrey A.Rose
Division of Cardiology,Sanger Heart and Vascular
Institute—Chief
None None None None n Medtronic None
Richard J.Shemin
Ronald Reagan UCLAMedical Center,
Cardiovascular Center—Director of Cardiac
Quality, Robert and KellyDay Professor, Chief ofCardiothoracic
Surgery,Executive Vice Chair of
Surgery
n EdwardsLifesciences
n Sorin Group
None None None None None
Jacqueline E.Tamis-Holland
Saint Luke’s Hospital,Icahn School of Medicineat Mount Sinai
HospitalMount Sinai—Director,Women’s Heart NY,
Assistant Professor ofMedicine, Director,
Interventional CardiologyFellowship
None None None None None None
Carl L. Tommaso Rush Medical College inChicago, Skokie
IllinoisHospital, part of theNorthshore University
Health System—Directorof the CardiacCatheterization
Laboratory, AssociateProfessor of Medicine
None None None None None None
L. Samuel Wann Columbia St.
Mary’sHealthcare—ClinicalCardiologist, MedicalDirector, Heart
Failure
Program
n UnitedHealthcare
None None None None None
John B. Wong Tufts University School ofMedicine—Chief,
Division
of Clinical DecisionMaking, Primary CarePhysician, Principal
Investigator, Institute forClinical Research andHealth Policy
Studies,
Professor
None None None None None None
Continued on the next page
APPENDIX B. CONTINUED
J A C C V O L . - , N O . - , 2 0 1 6 Patel et al.- , 2 0 1 6 :-
–- AUC for Coronary Revascularization in Patients With ACS
19
-
Participant Employment ConsultantSpeakersBureau
Ownership/Partnership/Principal
PersonalResearch
Institutional,Organizational,
or OtherFinancialBenefit
ExpertWitness
Reviewers
Jeffrey L.Anderson
Intermountain MedicalCenter—Associate Chief of
Cardiology
n Sanofi-Aventisn The Medicines
Company
None None None None None
Jeffrey A.Brinker
Johns Hopkins Hospital—Professor of Medicine
None None None None None None
Alexandru I.Costea
University of CincinnatiMedical Center—Associate
Professor
None None None None n BostonScientific*
None
Ali E. Denktas Baylor College ofMedicine—Assistant
Professor
None None None n AstraZenecan Edwards
Lifesciences
None None
Lloyd W. Klein Melrose Park—Professor ofMedicine
None None None None None None
Frederick G.Kushner
Tulane University MedicalCenter, Heart Clinic
ofLouisiana—ClinicalProfessor, Medical
Director
None None None None None None
Glenn N. Levine Baylor College ofMedicine, Cardiology—
Professor
None None None None None None
David J. Maron Stanford University Schoolof Medicine—Professor
ofMedicine and Emergency
Medicine
None None None None None None
James B.McClurken
Temple University, Schoolof Medicine, Richard A Reif
Heart Institute,Doylestown Hospital—Director of ThoracicSurgery,
Professor ofSurgery Emeritus
None None None None None None
Robert N. Piana Vanderbilt UniversityMedical Center—Professorof
Medicine, Cardiology
n Axio Researchn Harvard Clinical
ResearchInstitute
n W.L. Gore &Associates, Inc.
None None None None None
John A. Spertus Washington UniversitySchool of Medicine—Adjunct
Professor of
Medicine
n Amgenn Bayer Health-
carePharmaceuticals
n Janssenn Novartisn Regeneron
None n HealthOutcomesSciences
None None None
Raymond F.Stainback
Texas Heart Institute atBaylor St. Luke’s MedicalCenter,
Non-InvasiveCardiology—Medical
Director
None None None None None None
Robert C. Stoler Cardiology Consultants ofTexas—Director of
Cardiac
CatheterizationLaboratory
n Boston Scientificn Medtronic
None None None None None
Continued on the next page
APPENDIX B. CONTINUED
Patel et al. J A C C V O L . - , N O . - , 2 0 1 6
AUC for Coronary Revascularization in Patients With ACS - , 2 0
1 6 :- –-20
-
Participant Employment ConsultantSpeakersBureau
Ownership/Partnership/Principal
PersonalResearch
Institutional,Organizational,
or OtherFinancialBenefit
ExpertWitness
Todd C. Villines Cardiology Service atWalter Reed Army
MedicalCenter—Co-Director of
Cardiovascular ComputedTomography and Assistant
Chief
n BoehringerIngelheim†
None None None None None
David H. Wiener Jefferson Medical College,Jefferson Heart
Institute—
Professor of Medicine
None None None None None None
Appropriate Use Criteria Task For