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APPROPRIATE USE CRITERIA
ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use
Criteria forCoronary Revascularization in PatientsWith Stable
Ischemic Heart Disease
A Report of the American College of Cardiology Appropriate Use
Criteria Task Force,American Association 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 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, FAHA*James Aaron Grantham,
MD, FACCThomas M. Maddox, MD, MSC, FACC, FAHA
This document was approved by the American College of Cardiology
Cl
January 2017.
The American College of Cardiology requests that this document
be cited
Maron DJ, Smith PK. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017
appro
ischemic heart disease: 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 S
This document has been reprinted in the Journal of Nuclear
Cardiology an
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. Requests may
be compl
author-agreement/obtaining-permission).
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, FSCAI, FAHA,Writing Group
Liaison*Peter K. Smith, MD, FACC, Writing Group Liaison
James C. Blankenship, MD, MACC, MSCAIz
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, FACCkMark
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*
inical Policy Approval Committee on behalf of the Board of
Trustees in
as follows: Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox
TM,
priate use criteria for coronary revascularization in patients
with stable
priate Use Criteria Task Force, American Association for
Thoracic Surgery,
an Society of Nuclear Cardiology, Society for Cardiovascular
Angiography
ociety of Thoracic Surgeons. J Am Coll Cardiol
2017;69:2212–41.
d the Journal of Thoracic and Cardiovascular Surgery.
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
eted online via the Elsevier site
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-
J A C C V O L . 6 9 , N O . 1 7 , 2 0 1 7 Patel et al.M A Y 2 ,
2 0 1 7 : 2 2 1 2 – 4 1 AUC for Coronary Revascularization in
Patients With SIHD
2213
L. Samuel Wann, MD, MACC**John B. Wong, MDz
zAmerican College of Cardiology Representative.xAmerican Heart
Association Representative.
kSociety of Thoracic Surgeons Representative.
{AmericanAssociation for Thoracic Surgery Representative. #American
Society
of Echocardiography Representative. **American Society of
Nuclear
Cardiology Representative.
Appropriate UseCriteria TaskForce
John U. Doherty, MD, FACC, Co-ChairGregory J. Dehmer, MD, MACC,
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 2214
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 2214
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 2214
2. METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 2215
Indication Development . . . . . . . . . . . . . . . . . . . . .
. . 2215
Scope of Indications . . . . . . . . . . . . . . . . . . . . . .
. . . . . 2217
Figure 1 AUC Development Process . . . . . . . . . . . . . .
2217
3. ASSUMPTIONS . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 2218
General Assumptions . . . . . . . . . . . . . . . . . . . . . .
. . . . 2218
Assumptions for Rating Multiple TreatmentOptions . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2219
4. DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 2219
Table A. Revascularization to Improve SurvivalCompared With
Medical Therapy . . . . . . . . . . . . . . . . 2220
Table B. Noninvasive Risk Stratification . . . . . . . . . . .
2222
5. ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 2223
6. CORONARY REVASCULARIZATION IN
PATIENTS WITH STABLE ISCHEMIC
HEART DISEASE: APPROPRIATE USE
CRITERIA (BY INDICATION) . . . . . . . . . . . . . . . . . .
2223
Section 1. SIHD Without Prior CABG . . . . . . . . . . . . . .
2223
Table 1.1 One-Vessel Disease . . . . . . . . . . . . . . . . .
2224
Table 1.2 Two-Vessel Disease . . . . . . . . . . . . . . . . .
2225
Table 1.3 Three-Vessel Disease . . . . . . . . . . . . . . . .
2226
Table 1.4 Left Main Coronary Artery Stenosis . . . . 2227
Section 2. Tables 2.1 and 2.2 SIHD With Prior CABG . 2226
Table 2.1 IMA to LAD Patent and WithoutSignificant Stenoses . .
. . . . . . . . . . . . . . . . . . . . . . 2228
Table 2.2 IMA to LAD Not Patent . . . . . . . . . . . . . .
2229
Section 3. Table 3.1 SIHD Undergoing Procedures forWhich
Coronary Revascularization May BeConsidered . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 2227
Table 3.1 Stable Ischemic Heart DiseaseUndergoing Procedures for
Which CoronaryRevascularization May Be Considered . . . . . . . . .
. 2230
7. DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 2228
APPENDIX A
ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS2017 Appropriate Use Criteria
for CoronaryRevascularization in Patients With StableIschemic Heart
Disease: Participants . . . . . . . . . . . . . 2233
APPENDIX B
Relationships With Industry and Other Entities . . . . 2235
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ABSTRACT
The American College of Cardiology, Society for Cardio-vascular
Angiography and Interventions, Society ofThoracic Surgeons, and
American Association for ThoracicSurgery, along with key specialty
and subspecialty soci-eties, have completed a 2-part revision of
the appropriateuse criteria (AUC) for coronary revascularization.
In priorcoronary revascularization AUC documents, indications
forrevascularization in acute coronary syndromes and stableischemic
heart disease (SIHD) were combined into 1 docu-ment. To address the
expanding clinical indications forcoronary revascularization, and
to align the subject matterwith the most current American College
of Cardiology/American Heart Association guidelines, the new AUC
forcoronary artery revascularization were separated into 2documents
addressing SIHD and acute coronary syndromesindividually. This
document presents the AUC for SIHD.
Clinical scenarios were developed to mimic patient
pre-sentations encountered in everyday practice. These sce-narios
included information on symptom status; risk levelas assessed by
noninvasive testing; coronary diseaseburden; and, in some
scenarios, fractional flow reservetesting, presence or absence of
diabetes, and SYNTAX score.This update provides a reassessment of
clinical scenariosthat the writing group felt were affected by
significantchanges in the medical literature or gaps from prior
criteria.The methodology used in this update is similar to the
initialdocument but employs the recent modifications in themethods
for developing AUC, most notably, alterations inthe nomenclature
for appropriate use categorization.
A separate, independent rating panel scored the clin-ical
scenarios on a scale of 1 to 9. Scores of 7 to 9 indicatethat
revascularization is considered appropriate for theclinical
scenario presented. Scores of 1 to 3 indicate thatrevascularization
is considered rarely appropriate for theclinical scenario, whereas
scores in the mid-range of 4 to 6indicate that coronary
revascularization may be appro-priate for the clinical
scenario.
As seen with the prior coronary revascularization
AUC,revascularization in clinical scenarios with high
symptomburden, high-risk features, and high coronary diseaseburden,
as well as in patients receiving antianginal ther-apy, are deemed
appropriate. Additionally, scenariosassessing the appropriateness
of revascularization beforekidney transplantation or transcatheter
valve therapy arenow rated. The primary objective of the AUC is to
providea framework for the assessment of practice patterns thatwill
hopefully improve physician decision making.
PREFACE
The American College of Cardiology (ACC), in collabora-tion with
the Society for Cardiovascular Angiography and
Interventions, Society of Thoracic Surgeons, AmericanAssociation
for Thoracic Surgery, and other societies,developed and published
the first version of the AUC forcoronary revascularization in 2009,
releasing the lastupdate in 2012. The AUC are an effort to assist
cliniciansin the rational use of coronary revascularization
incommon clinical scenarios found in everyday practice.The new AUC
for coronary revascularization weredeveloped as separate documents
for stable ischemicheart disease (SIHD) and acute coronary
syndromes. Thiswas done to address the expanding clinical
indicationsfor coronary revascularization, include new
literaturepublished since the last update, and align the
subjectmatter with the ACC/American Heart Association guide-lines.
An additional goal was to address several of theshortcomings of the
initial document that becameevident as experience with the use of
the AUC accumu-lated in clinical practice.
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 tosupport 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 underuse.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 on the merits of
coronary revas-cularization for various clinical scenarios. We
would alsolike to thank the parent AUC Task Force and the
ACCstaff—Joseph Allen, Leah White, and specifically,
MariaVelasquez—for their skilled support in the generation ofthis
document.
Manesh R. Patel, MD, FACC, FAHA, FSCAIChair, Coronary
Revascularization Writing Group
Immediate Past Chair, Appropriate Use Criteria Task Force
Michael J. Wolk, MD, MACC, Moderator,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
CoronaryRevascularization AUC (1). Since publication of the 2012AUC
focused update, the original nomenclature used to
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J A C C V O L . 6 9 , N O . 1 7 , 2 0 1 7 Patel et al.M A Y 2 ,
2 0 1 7 : 2 2 1 2 – 4 1 AUC for Coronary Revascularization in
Patients With SIHD
2215
characterize appropriate use has changed (2). New
clinicalpractice guidelines (CPGs) for SIHD have been released,and
new clinical trials extending the knowledge and evi-dence around
coronary revascularization have been pub-lished (3,4). These trials
include studies not only on theuse of percutaneous coronary
intervention (PCI), but alsoon coronary artery bypass graft surgery
(CABG), medicaltherapy, and diagnostic technologies such as
fractionalflow reserve (FFR) to guide revascularization
(5–8).Additional studies, some based on data from the
NationalCardiovascular Data Registry (NCDR), have been pub-lished
providing insights into practice patterns and in-formation around
clinical scenarios and patient featuresnot previously addressed
(9–13).
Improvements in our understanding of the variablesaffecting
patient outcomes before and after coronaryrevascularization,
continued emphasis on the role ofmedical therapy for coronary
artery disease (CAD), and anincreasing emphasis on shared decision
making and pa-tient preferences also make a revision of the
coronaryrevascularization AUC timely (14). This document focuseson
SIHD and is a companion to the AUC specifically foracute coronary
syndromes.
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 priorcoronary revascularization AUC. The
writing group wastasked with developing clinical indications
(scenarios)that reflect typical situations encountered in
everydaypractice that were then rated by a technical panel. In
thisdocument, the term “indication” is used interchangeablywith the
phrase “clinical scenario.” Critical data elementsand mapping of
the criteria to the elements will be pro-vided for end-users of the
revascularization AUC so thatprocedure notes and chart abstraction
can be more easilymapped to the AUC. A key goal of this effort is
to leveragethe NCDR (National Cardiovascular Data Registry)
Cath-PCI registry to map indications to appropriateness ratings,so
that minimal additional data collection is needed tosupport
quarterly feedback to sites of their performanceas a foundation for
improving patient selection forrevascularization. The AUC Task
Force is committed tosupporting linkage of the AUC with daily
workflow tocapture the data elements needed for AUC ratings.
The revascularization AUC are based on our currentunderstanding
of procedure outcomes plus the potentialpatient benefits and risks
of the revascularization strate-gies examined. Although the AUC are
developed toaddress many of the common clinical scenarios
encountered in practice, it would be impossible to includeevery
conceivable patient presentation and maintain aworkable document
for clinicians. The writing group ac-knowledges that the current
AUC do not evaluate all pa-tient variables that might affect 1 or
more strategies forthe management of patients with CAD. Examples of
con-ditions not explicitly considered within the scenariosinclude
severe chronic kidney disease, severe peripheralvascular disease,
known malignancies, poor lung func-tion, advanced liver disease,
advanced dementia, and/orother comorbidities that might have
excluded patientsfrom the clinical trials that provide the evidence
base forcoronary revascularization. Nevertheless, it is
necessaryfor the clinician to include these conditions in the
finaldecision-making process for an individual patient, andthis may
result in the actual therapy deviating from theAUC rating. It is
expected that all clinicians will occa-sionally treat patients with
extenuating conditions thatare not captured in the current AUC, and
this could resultin a treatment rating of “rarely appropriate” for
the cho-sen therapy in a specific patient. However, these
situa-tions should not constitute a majority of treatmentdecisions,
and it is presumed that they will affect allpractitioners equally,
thereby minimizing substantialbiases in assessing the performance
of individual clini-cians compared with their peers. Additionally,
these AUCwere developed in parallel with efforts to update
datacollection within the NCDR registries to include datafields
that capture some of these extenuating circum-stances, thereby
improving the characterization of sce-narios in the AUC.
AUC documents often contain specific clinical sce-narios rather
than the more generalized situationscovered in CPGs; thus, subtle
differences between thesedocuments may exist. The treatment of
patients withSIHD should always include therapies to modify
riskfactors and/or reduce cardiovascular events—so-calledsecondary
prevention. In several CPGs, the phrase“guideline-directed medical
therapy” is used and,depending on the context, may include the use
of anti-anginal therapy in addition to therapies for
secondaryprevention. In this AUC, it is assumed that all patients
willbe receiving comprehensive secondary prevention thera-pies as
needed. Antianginal therapy has a central role inthe treatment of
patients with SIHD. In some patients, itmay be the sole therapy,
whereas in others it may becontinued, albeit in lower doses,
following a revasculari-zation procedure. The earlier coronary
revascularizationAUC included information about the intensity of
anti-anginal therapy in several scenarios, with language suchas
“receiving no or minimal anti-ischemic therapy” or“receiving a
course of maximal anti-ischemic therapy.”The new AUC adopts a
different format, including optionsfor the initiation or escalation
of antianginal therapy
-
Sco
Sco
Sco
Patel et al. J A C C V O L . 6 9 , N O . 1 7 , 2 0 1 7
AUC for Coronary Revascularization in Patients With SIHD M A Y 2
, 2 0 1 7 : 2 2 1 2 – 4 12216
patterned after recommendations made in the 2012
ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diag-nosis and
Management of Patients With Stable IschemicHeart Disease (2012 SIHD
guideline) (3), using a structurethat mimics clinical practice.
However, the primary pur-pose of these AUCs is to rate the
appropriateness ofrevascularization with the understanding that
decisionsabout revascularization are frequently made in thecontext
of ongoing antianginal therapy. Because recom-mendations for
revascularization or the medical man-agement of CAD are found
throughout several CPGs, theAUC ratings herein are meant to unify
related CPGs andother data sources and provide a useful tool for
clinicians.
These AUC were developed with the intent of assistingpatients
and clinicians, but they are not intended todiminish the
acknowledged complexity or uncertainty ofclinical decision making
and should not be used as asubstitute for sound clinical judgment.
There areacknowledged evidence gaps in many areas where
clinicaljudgment and experience must be blended with
patientpreferences and the existing knowledge base defined inCPGs.
It is important to emphasize that a rating ofappropriate care does
not mandate that a revasculariza-tion procedure be performed;
likewise, a rating of rarelyappropriate care should not prevent a
revascularizationprocedure from being performed. It is anticipated,
asnoted in the previous text, that there will be occasionalclinical
scenarios rated rarely appropriate in which per-forming
revascularization may still be in the best interestof a particular
patient. In situations in which the AUCrating is not followed,
clinicians should document thespecific patient features not
captured in the clinical sce-nario or the rationale for the chosen
therapy. Dependingon the urgency of care, convening a heart team
orobtaining a second opinion may be helpful in some ofthese
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 of comparingutilization patterns among providers to
thereby derive anassessment of an individual clinician’s
managementstrategies compared with his/her peers. It is critical
tounderstand that the AUC should be used to assess anoverall
pattern of clinical care rather than being the finalarbitrator of
specific individual cases. The ACC and itscollaborators believe
that an ongoing review of one’spractice using these criteria will
help guide more effec-tive, efficient, and equitable allocation of
healthcare re-sources, and ultimately, better patient
outcomes.However, under no circumstances should the AUC be
used to adjudicate or determine payment for individual
patients. Rather, the intent of the AUC is to provide a
framework to evaluate overall clinical practice patterns
and 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 is appropriate carewhen the
potential benefits, in terms of survival orhealth outcomes
(symptoms, functional status, and/
or quality of life), exceed the potential negativeconsequences
of the treatment strategy.
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 to
assesswhether the use of revascularization for each indication
is“appropriate care,” “may be appropriate care,” or is“rarely
appropriate care” using the following definitionsand their
associated numeric ranges. Anonymized indi-vidual scores are
available in an online appendix.
Median Score 7 to 9: Appropriate Care
An appropriate option for management of patients in
thispopulation, as the benefits generally outweigh the 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
benefit to risk ratio, potentialbenefit based on practice
experience in the absence ofevidence, and/or variability in the
population; effective-ness for individual care must be determined
by a patient’sphysician in consultation with the patient on the
basis ofadditional clinical variables and judgment along
withpatient preferences (i.e., procedure may be acceptableand may
be reasonable for the indication).
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).
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2217
The process for development of the AUC is shown inFigure 1 and
described in detail in previous documents(1,2).
After completion and tabulation of the second round ofratings,
it became apparent to the writing group that theoriginal structure
of certain rating tables may haveconfused some members of the
rating panel, causingratings that were not internally consistent.
This resultedin a re-evaluation and redesign of the rating table
struc-ture, which then required a third round of ratings. ThisAUC
document presents the end result of that process andthe results of
the third round of ratings.
Scope of Indications
The indications for coronary revascularization in
SIHDweredeveloped considering the following common variables:
1. The clinical presentation (e.g., low or high activitylevel to
provoke ischemic symptoms);
2. Use of antianginal medications;3. Results of noninvasive
tests to evaluate the presence
and severity of myocardial ischemia;4. Presence of other
confounding factors and comorbid-
ities such as diabetes;5. Extent of anatomic disease;6. Prior
coronary artery bypass surgery; and
FIGURE 1 AUC Development Process
Develop list of indications, assumptions, and definitions
Review Panprovid
Writing Gind
Rating Pindication
1st round
2nd round–
Approp(7–9) Ap(4–6) MaAppropr(1–3) RaApproprProspective
comparison
with clinical records
% use that is Appropriate, May Be
Appropriate, or Rarely Appropriate
Indi
catio
n D
evel
opm
ent
App
ropr
iate
ness
D
eter
min
atio
nV
alid
atio
n
AUC indicates appropriate use criteria.
7. Invasive testing such as intravascular ultrasound(IVUS) and
invasive physiology such as FFR.
The anatomic construct for CAD is based on the pres-ence or
absence of flow-limiting obstructions in the cor-onary arteries
categorized by the number of vesselsinvolved (1-, 2-, and 3-vessel,
and/or left main CAD).Additionally, we included in the anatomic
construct thepresence or absence of proximal left anterior
descending(LAD) disease. This specific stenosis location was
identi-fied in both the 2011 ACCF/AHA guideline for coronaryartery
bypass graft surgery (2011 CABG guidelines) and2012 ACC/AHA/SCAI
guideline for percutaneous coronaryintervention (2012 PCI
guidelines) and was included inclinical trial recruitment to guide
revascularization de-cisions (6,15,16). Other factors such as
diabetes and thecomplexity of disease were included in certain
clinicalscenarios given their effect on cardiac risk and
associationwith more favorable outcomes from surgical
revasculari-zation. As before, noninvasive test findings are
includedin many scenarios to distinguish patients with a low
riskfor future adverse events from those with intermediate-or
high-risk findings, as these terms are routinely used inclinical
practice.
Antianginal treatment of CAD is incorporated into thestructure
of the tables following the pattern of
Literature review and guideline mapping
el >30 members e feedback
roup revises ications
anel rates the s in 2 rounds
–no interaction
panel interaction
riate Use Scorepropriatey Beiate rely iate
Prospective clinical decision aids
Increase appropriate use
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AUC for Coronary Revascularization in Patients With SIHD M A Y 2
, 2 0 1 7 : 2 2 1 2 – 4 12218
recommendations in the SIHD guideline (see 2012 SIHDguidelines,
Section 4.4.3.1.) but without specific drug ordose recommendations
(3,4). In general, beta blockers arerecommended as the initial
treatment for symptom relief(Class I recommendation), with calcium
channel blockers,long-acting nitrates, or ranolazine prescribed in
combi-nation with beta blockers when initial treatment with
betablockers is inadequate to control symptoms despiteappropriate
dosing. Calcium channel blockers, long-acting nitrates, or
ranolazine should be prescribed forrelief of symptoms when beta
blockers are contra-indicated or cause unacceptable side effects.
Long-actingnondihydropyridine calcium channel blockers
arereasonable alternatives to beta blockers as first-linetherapy
for antianginal symptoms (Class IIa, Level ofEvidence: B). The use
of FFR was incorporated to a greaterextent than in the previous AUC
as more data on theusefulness of this testing modality have
emerged.
3. ASSUMPTIONS
General Assumptions
Specific assumptions provided to the rating panel for theiruse
in rating the relevant clinical scenarios are summa-rized in the
following text.
1. When available, each clinical scenario includes thepatient’s
clinical status/symptom complex, ischemicburden as determined by
noninvasive functionaltesting, burden of coronary atherosclerosis
as deter-mined by angiography, and additional invasivetesting
evaluations by invasive physiology (e.g., FFR,instantaneous
wave-free ratio) or intravascularimaging.
2. When utilized, stress testing, with or without anassociated
imaging procedure, was performedcorrectly and with sufficient
quality to produce ameaningful and accurate result within the
limits ofthe test performance. Evidence of myocardial viabilityis
also an important finding and in some clinical sit-uations may
influence the decision for revasculariza-tion, but it was not used
to further expand the numberof indications.
3. As the main focus of this AUC is revascularization,assume
that coronary angiography has been per-formed. The rating panel
should judge the appropri-ateness of revascularization on the basis
of the clinicalscenario presented, including the coronary
diseaseidentified, independent of a judgment about
theappropriateness of the coronary angiogram in thescenario.
4. Assume no other significant coronary artery stenosesare
present except those specifically described in theclinical
scenario.
5. A significant coronary stenosis for the purpose of
theclinical scenarios is defined as:
n $70% luminal diameter narrowing, by visualassessment, of an
epicardial stenosis measured inthe “worst view” angiographic
projection;
n $50% luminal diameter narrowing, by visualassessment, of a
left main stenosis measured inthe “worst view” angiographic
projection; or
n 40% to 70% luminal narrowing, by visual assess-ment, of an
epicardial stenosis measured in the“worst view” angiographic
projection with anabnormal FFR as defined in the following
text.
6. An FFR #0.80 is abnormal and is consistent withdownstream
inducible ischemia.
7. All patients included in these scenarios are receivingneeded
therapies to modify existing risk factors asoutlined in CPGs and
other documents (17–19). Despitethe best efforts of the clinician,
all patients may notachieve target goals for cardiac risk factor
modifica-tion. However, a continuing effort and plan of care
toaddress risk factors are assumed to exist.
8. For patients with SIHD, the writing group recognizesthere are
many choices for antianginal therapy andconsiderable variation in
the use and tolerance ofantianginal medications among patients. The
use ofantianginal therapy adopted in this AUC follows
therecommendations of the SIHD guideline. Assume thatantianginal
therapy is prescribed at a dose thatadequately controls the
patient’s symptoms or is themaximally tolerated dose for a
particular drug.
9. Operators performing percutaneous or
surgicalrevascularization have appropriate clinical trainingand
experience and have satisfactory outcomes asassessed by quality
assurance monitoring (15,20,21).
10. Revascularization by either percutaneous or surgicalmethods
is performed in a manner consistent withestablished standards of
care at centers with quality/volume standards (15,20,21).
11. In the clinical scenarios, no unusual extenuating
cir-cumstances exist (e.g., an inability to comply withantiplatelet
agents, do-not-resuscitate status, a pa-tient unwilling to consider
revascularization, tech-nical reasons rendering revascularization
infeasible,or comorbidities likely to markedly increase proce-dural
risk). If any of these circumstances exist, it iscritical that the
clinician provide adequate documen-tation in the medical record to
support exclusionsfrom the AUC and the alternative management
de-cisions made in the patient.
12. Patient history and physical examination are assumedto be
comprehensive and thorough. Descriptions ofthe patient’s symptoms
are assumed to accuratelyrepresent the current status of the
patient (e.g.,asymptomatic patients are truly asymptomatic
rather
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than asymptomatic due to self-imposed lifestylelimitations).
13. When PCI is being considered in patients with multi-vessel
disease, it may be clinically prudent to performthe procedures in a
sequential fashion (so-called“staged procedures”). If this is the
initial managementplan, the intent for a staged procedure should
beclearly outlined and the appropriateness rating shouldapply to
the entire revascularization procedure. Spe-cifically, planned
staged procedures should not beassessed by individual arteries but
rather in terms ofthe plan for the entire revascularization
strategy. Fordata collection purposes, this will require
document-ing how the procedure is staged (either PCI or
hybridrevascularization with surgery), and it is assumed thatall
stenoses covered under the umbrella of the plan-ned staged
procedure are functionally significant.
14. Although the clinical scenarios should be rated on thebasis
of the published literature, the writing committeeacknowledges that
decisions about coronary arteryrevascularization in patient
populations that are poorlyrepresented in the literature are still
required in dailypractice. Therefore, rating panel members should
as-sume that some of the clinical scenarios presented willhave low
levels of evidence to guide rating decisions.Key to the application
of the AUC in settings wherethere are extenuating circumstances or
low levels ofsupporting evidence is enhanced documentation bythe
clinician to support the clinical decisions made.
15. As with all previously published clinical policies,
de-viations by the rating panel from prior publisheddocuments were
directed by new evidence that jus-tifies such evolution. However,
the reader is advisedto pay careful attention to the wording of an
indica-tion in the present document when making compari-sons to
prior publications.
16. Indication ratings contained herein supersede theratings of
similar indications contained in previousAUC coronary
revascularization documents.
Assumptions for Rating Multiple Treatment Options
1. The goal of this document is to identify revasculariza-tion
treatments that are considered reasonable for agiven clinical
indication. Therefore, each treatmentoption (PCI or CABG) should be
rated independently forits level of appropriateness in the specific
clinical sce-nario, rather than being placed into a forced or
artificialrank-order comparison against each other.
Identifyingoptions that may or may not be reasonable for
specificindications is the goal of this document, rather
thandetermining a single best treatment for each clinical
indication or a rank-order. Therefore, more than 1treatment or
even all treatments may be considered
“Appropriate,” “May Be Appropriate,” or “RarelyAppropriate” for
any given clinical indication.
2. If more than 1 treatment falls into the same appropriateuse
category, it is assumed that patient preferencecombined with
physician judgment and available localexpertise will be used to
determine the final treatmentused.
4. DEFINITIONS
Definitions of some key terms used throughout the sce-narios are
shown in the following text. A complete set ofdefinitions is found
in Appendix A. These definitions wereprovided to and discussed with
the rating panel beforethe rating process started.
Indication
A set of patient-specific conditions defines an “indica-tion.”
The term “clinical indication” (used interchange-ably with
“clinical scenario”) provides the context for therating of
therapeutic options. However, an “appropriate”rating assigned by
the rating panel does not necessarilymean the therapy is mandatory,
nor does a “rarelyappropriate” rating mean it is prohibited.
Risk Factor Modification (Secondary Prevention) andAntianginal
Medical Therapy
As previously stated, the indications assume that patientsare
receiving all indicated treatments for the secondaryprevention of
cardiovascular events. This includes life-style and pharmacological
interventions according toguideline-based recommendations.
Antianginal medicaltherapy is incorporated into the structure of
the ratingtables and should follow the recommendations of theSIHD
guideline, with a beta blocker as initial therapy andthe option to
administer calcium channel blockers, long-acting nitrates, and/or
ranolazine if the beta blocker isineffective or not tolerated
(3,4).
Specific target doses of drugs are not provided as thismust be
individualized, but for beta blockers, it isassumed the dose is
sufficient to blunt the exercise heartrate without causing
intolerable fatigue, bradycardia, orhypotension. It is assumed that
the maximally tolerateddose of beta blockers is being used before
the addition ofother drugs, and when other drugs are added, the
dose istitrated to alleviate symptoms or is also the
maximallytolerated dose. Using multiple drugs at less than
optimaldoses is an inefficient and expensive strategy. The
SIHDguideline recommends calcium channel blockers or long-acting
nitrates if beta blockers are contraindicated orcause unacceptable
side effects. The SIHD guideline alsorecommends adding calcium
channel blockers or long-acting nitrates to beta blockers for
relief of symptomswhen initial treatment with beta blockers is
unsuccessful.
-
TABLE
AnatomicSetting
UPLM or c
CABG a
CABG a
UPLM*
CABG
PCI
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Initiating, continuing, or intensifying antianginal therapyis
integrated into the ratings tables along with revascu-larization
options, as this is typical of real-world practice.
Stress Testing and Risk of Findings on Noninvasive Testing
Stress testing is commonly used for both diagnosis andrisk
stratification of patients with CAD. Therapies toimprove survival
in patients with SIHD are outlined indetail in the 2012 SIHD
guideline (Table A) (3). The variousnoninvasive findings associated
with high (>3% annualdeath or myocardial infarction),
intermediate (1% to 3%annual death or myocardial infarction) and
low (
-
TABLE A Continued
AnatomicSetting COR LOE References
3-vessel disease with or without proximal LAD artery
disease*
CABG I B (353,412,959,985–987)
IIa—It is reasonable to choose CABG over PCI in patients with
complex 3-vessel CAD(e.g., SYNTAX score >22) who are good
candidates for CABG.
B (964,980,987–989)
PCI IIb—Of uncertain benefit B (366,959,980,985,987)
2-vessel disease with proximal LAD artery disease*
CABG I B (353,412,959,985–987)
PCI IIb—Of uncertain benefit B (366,959,985,987)
2-vessel disease without proximal LAD artery disease*
CABG IIa—With extensive ischemia B (327,990–992)
IIb—Of uncertain benefit without extensive ischemia C (987)
PCI IIb—Of uncertain benefit B (366,959,985,987)
1-vessel proximal LAD artery disease
CABG IIa—With LIMA for long-term benefit B (412 987,993,994)
PCI IIb—Of uncertain benefit B (366,959,985,987)
1-vessel disease without proximal LAD artery involvement
CABG III: Harm B (306,327,412,985,990,995–998)
PCI III: Harm B (306,327,412,985,990,995–998)
LV dysfunction
CABG IIa—EF 35% to 50% B (365,412,999–1002)
CABG IIb—EF
-
TABLE B Noninvasive Risk Stratification
High risk (>3% annual death or MI)1. Severe resting LV
dysfunction (LVEF
-
BB
CA
CA
FF
IM
LA
LV
PC
SIH
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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 (SDM) de-scribes a collaborative approach
whereby patients areprovided with evidence-based information on
treatmentchoices and encouraged to use the information in
aninformed dialogue with their provider to make decisionsthat not
only use the scientific evidence, but also alignwith their values,
preferences, and lifestyle (26–28). Thealternative decision
paradigm, often referred to as medi-cal paternalism, places
decision authority with physiciansand assigns the patient a more
passive role (29). SDM re-spects both the provider’s knowledge and
the patient’sright to be fully informed of all care options with
theirassociated risks and benefits. SDM often uses decisionaids
such as written materials, online modules, or videosto present
information about treatment options that helpthe patient evaluate
the risks and benefits of a particulartreatment. The most effective
decision aids to help pa-tients make truly informed decisions
provide relevantfacts and videos of real patient perspectives
regarding theparticular treatment (30). Many professional
organiza-tions now endorse SDM in practice (31,32).
More than 1 treatment option often exists with no clearevidence
identifying the best option. This is compoundedwhen there is
variation in experts’ recommendationsabout the best treatment under
different circumstances(33). A challenging situation exists when
scientific datasuggest 1 treatment is likely to have better
outcomes, yetthe patient prefers an alternative treatment. Within
thecontext of the AUC, this would be manifest as the
patientrequesting a therapy with a lower AUC rating (e.g.,wanting a
therapy rated as rarely appropriate when atherapy rated appropriate
exists). Informed consent isfundamental to SDM (34). Without
understanding the prosand cons of all treatment options, patients
cannot properlyengage in SDM and blend their personal desires with
thescientific data. Without question, it is important thatblending
AUC ratings into clinical decision making providea pathway for
including patient preference and SDM.However, the mechanism for
that process is beyond thescope of this AUC document. The purpose
of this docu-ment is to develop clinical scenarios and provide
ratings ofthose scenarios by an expert panel. A complete
discussionabout treatment options with SDM can only be
finalizedonce the category of appropriate use is determined.
5. ABBREVIATIONS
AA
AC
AU
¼ antianginalS ¼ acute coronary syndromeC ¼ appropriate use
criteria
¼ beta-blockersBG ¼ coronary artery bypass graftD ¼ coronary
artery diseaseR ¼ fractional flow reserveA ¼ internal mammary
arteryD ¼ left anterior descending coronary arteryEF ¼ left
ventricular ejection fractionI ¼ percutaneous coronary
interventionD ¼ stable ischemic heart disease
6. CORONARY REVASCULARIZATION IN
PATIENTS WITH STABLE ISCHEMIC HEART
DISEASE: APPROPRIATE USE CRITERIA
(BY INDICATION)
Section 1. SIHD Without Prior CABG
The format for tables in Section 1 is similar, with
separatetables for 1-, 2-, and 3-vessel disease and left main
dis-ease. The columns in each table are stratified into 2
cat-egories. There is a single column combining patients whoare
asymptomatic and not receiving antianginal therapywith patients who
are asymptomatic and receiving anti-anginal therapy. The remaining
columns are devoted topatients with ischemic symptoms, with 3
separate cate-gories: ischemic symptoms and receiving no
antianginaltherapy, ischemic symptoms and receiving 1
antianginaldrug (beta blocker preferred), and ischemic
symptomsreceiving 2 or more antianginal drugs. As outlined in
theSIHD guideline, in the absence of contraindications,initial
therapy should be a beta blocker prescribed at adose that reduces
heart rate without excessive restingbradycardia, hypotension, or
fatigue. Other antianginaldrugs are then added to beta blockers
depending on theindividual needs of the patient until symptoms are
sup-pressed to the satisfaction of the patient or higher
dosescannot be used because of side effects. In each of
thesubordinate columns, the panel was asked to rate theoptions for
revascularization, specifically PCI or CABG. Asnoted earlier, the
rating panel was asked to rate eachrevascularization option
independent of the other, withthe intent to rate each therapy on
its own merits ratherthan in comparison to the other option. In
this construct,both revascularization options could be assigned
identicalratings.
In this and subsequent tables, clinical scenarios oftencontain
the phrase “noninvasive testing.” In this docu-ment, that phrase
includes all forms of stress testing usingeither dynamic or
pharmacological stress that may becoupled with various imaging
tests. It also could includeother imaging, such as coronary
computed tomographyangiography or magnetic resonance imaging, to
assess
-
TABLE
Appropri
One-Vess
Indication
No Proxim
1.
2.
3.
Proximal
4.
5.
6.
The numbe
A indicatartery; LCX
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AUC for Coronary Revascularization in Patients With SIHD M A Y 2
, 2 0 1 7 : 2 2 1 2 – 4 12224
myocardial viability. Some would favor the term “func-tional
testing,” but the writing committee did not viewthis as inclusive
of computed tomography or magneticresonance imaging and thus
favored the term “noninva-sive testing.” FFR is considered as part
of an invasiveevaluation and is cited separately in some scenarios.
Anemerging technology, computed tomography-derivedFFR is a
combination technique that is noninvasive likecomputed tomography
but provides FFR, which hastraditionally only been an invasive
test.
Table 1.1. One-Vessel Disease
Similar to the 2011 CABG and 2012 SIHD guidelines, thisdocument
uses proximal LAD disease as an additionalanatomic discriminator
for 1-vessel CAD. Although dataare minimal, the writing committee
felt that proximaldisease of a dominant circumflex should be
considered ashigh-risk anatomy with similar implications as
proximalLAD disease, and thus, it was considered in a
separatesection along with proximal LAD disease.
Table 1.2. Two-Vessel Disease
The format of this table is similar to that for 1-vesseldisease.
Similar to the 2011 CABG and 2012 SIHD guide-lines, this document
makes a distinction regarding thepresence or absence of proximal
LAD disease. The writinggroup did not add proximal left dominant
circumflexdisease as an additional discriminator, because mostwould
consider an isolated stenosis in this location to be
1 .1 One-Vessel Disease
ate Use Score (1-9)
el Disease
Asymptomatic
Not on AATherapy or With
AA Therapy
PCI CABG
al LAD or Proximal Left Dominant LCX Involvement
n Low-risk findings on noninvasive testing R (2) R (1)
n Intermediate- or high-risk findings onnoninvasive testing
M (4) R (3)
n No stress test performed or, if performed,results are
indeterminate
n FFR #0.80*
M (4) R (2)
LAD or Proximal Left Dominant LCX Involvement Present
n Low-risk findings on noninvasive testing M (4) R (3)
n Intermediate- or high-risk findings onnoninvasive testing
M (5) M (5)
n No stress test performed or, if performed,results are
indeterminate
n FFR #0.80
M (5) M (5)
r in parentheses next to the rating reflects the median score
for that indication. *iFR measur
es appropriate; AA, antianginal; BB, beta blockers; CABG,
coronary artery bypass graft; FFR, fra, left circumflex artery; M,
may be appropriate; PCI, percutaneous coronary intervention;
and
the equivalent of 2-vessel disease (i.e., right coronaryartery
and circumflex disease). Following this construct,the combination
of proximal LAD disease and proximalleft dominant circumflex
disease would be considered as3-vessel disease and rated using the
3-vessel disease table(Table 1.3.). In the absence of exercise
data, invasivephysiological testing of both involved vessels is
includedin several of the indications. To remain in this table
of2-vessel disease, such testing must be abnormal in bothvessels.
If this testing shows only 1 vessel to be abnormal,the patient
would no longer be rated using this table, butrather would be rated
in the table for 1-vessel CAD.Finally, because of the increasing
body of literature thathas identified diabetes as an important
factor to considerwhen recommending revascularization, scenarios
indi-cating the presence of diabetes are provided.
Table 1.3. Three-Vessel Disease
Similar to Table 1.2., because of the increasing body
ofliterature that has identified diabetes as an importantfactor to
consider when recommending revascularization,categories indicating
the presence or absence of diabetesare provided among the
individual indications. Stenosiscomplexity is also an important
factor to consider in anyrevascularization procedure, probably more
so for PCIthan for CABG. The SYNTAX (Synergy between Percuta-neous
Coronary Intervention with TAXUS and CardiacSurgery) trial provided
a comprehensive comparison ofPCI and CABG and a structure that may
be helpful in
Ischemic Symptoms
Not on AATherapy
On 1 AA Drug(BB Preferred) On $2 AA Drugs
PCI CABG PCI CABG PCI CABG
R (3) R (2) M (4) R (3) A (7) M (5)
M (5) M (4) M (6) M (4) A (8) M (6)
M (5) R (3) M (6) M (4) A (8) M (6)
M (4) M (4) M (5) M (5) A (7) A (7)
M (6) M (6) A (7) A (7) A (8) A (8)
M (6) M (6) M (6) M (6) A (8) A (7)
ements with appropriate normal ranges may be substituted for
FFR.
ctional flow reserve; iFR, instant wave-free ratio; LAD, left
anterior descending coronaryR, rarely appropriate.
-
TABLE 1.2 Two-Vessel Disease
Appropriate Use Score (1–9)
Two-Vessel Disease
Indication
Asymptomatic Ischemic Symptoms
Not on AATherapy or With
AA TherapyNot on AATherapy
On 1 AA Drug(BB Preferred) On $2 AA Drugs
PCI CABG PCI CABG PCI CABG PCI CABG
No Proximal LAD Involvement
7. n Low-risk findings on noninvasive testing R (3) R (2) M (4)
R (3) M (5) M (4) A (7) M (6)
8. n Intermediate- or high-risk findings onnoninvasive
testing
M (5) M (4) M (6) M (5) A (7) M (6) A (8) A (7)
9. n No stress test performed or, if performed,results are
indeterminate
n FFR #0.80* in both vessels
M (5) M (4) M (6) M (4) A (7) M (5) A (8) A (7)
Proximal LAD Involvement and No Diabetes Present
10. n Low-risk findings on noninvasive testing M (4) M (4) M (5)
M (5) M (6) M (6) A (7) A (7)
11. n Intermediate- or high-risk findings onnoninvasive
testing
M (6) M (6) A (7) A (7) A (7) A (7) A (8) A (8)
12. n No stress test performed or, if performed,results are
indeterminate
n FFR #0.80 in both vessels
M (6) M (6) M (6) M (6) A (7) A (7) A (8) A (8)
Proximal LAD Involvement With Diabetes Present
13. n Low-risk findings on noninvasive testing M (4) M (5) M (4)
M (6) M (6) A (7) A (7) A (8)
14. n Intermediate- or high-risk findings onnoninvasive
testing
M (5) A (7) M (6) A (7) A (7) A (8) A (8) A (9)
15. n No stress test performed or, if performed,results are
indeterminate
n FFR #0.80 in both vessels*
M (5) M (6) M (6) A (7) A (7) A (8) A (7) A (8)
The number in parentheses next to the rating reflects the median
score for that indication. *iFR measurements with appropriate
normal ranges may be substituted for FFR.
A indicates appropriate; AA, antianginal; BB, beta blockers;
CABG, coronary artery bypass graft; FFR, fractional flow reserve;
iFR, instant wave-free ratio; LAD, left anterior descending
coronaryartery; M, may be appropriate; PCI, percutaneous coronary
intervention; and R, rarely appropriate.
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2225
formulating revascularization recommendations (35).Factors such
as vessel occlusion, bifurcation or trifurca-tion at branch points,
ostial stenosis location, length>20 mm, tortuosity,
calcification, and thrombus all add tothe complexity of PCI. The
presence of multiple complexfeatures (SYNTAX score >22) is
associated with morefavorable outcomes with CABG. Although
limitations ofthe SYNTAX score for certain revascularization
recom-mendations are recognized and it may be impractical toapply
this scoring system to all patients with multivesseldisease, it is
a reasonable surrogate for the extent andcomplexity of CAD and
provides important informationthat can be helpful when making
revascularizationdecisions.
Accordingly, in this table specifically for patients
with3-vessel disease, the rating panel was asked to considerthe
indications in patients with low complexity comparedwith those with
intermediate and high complexity.
Table 1.4. Left Main Coronary Artery Stenosis
Literature on the treatment of significant left main dis-ease is
dominated by surgical revascularization
procedures and, more recently, comparisons with PCI insome
anatomic situations. There are data suggesting thatstenting of the
left main ostium or trunk is morestraightforward than treating
distal bifurcation or trifur-cation stenoses and is associated with
a lower rate ofrestenosis. In comparison, left main lesion location
has anegligible influence on the success and long-term resultsof
CABG. Accordingly, there are separate rating optionsfor ostial and
mid-shaft left main disease and distal orbifurcation left main
disease. The definition of a signifi-cant left main stenosis used
herein is $50% narrowing byangiography. However, the angiographic
assessment ofthe severity of left main disease has several
shortcomings,and other assessments such as IVUS or FFR may
beneeded. For left main coronary artery stenoses, a mini-mum lumen
diameter of
-
TABLE 1.3 Three-Vessel Disease
Appropriate Use Score (1–9)
Three-Vessel Disease
Indication
Asymptomatic Ischemic Symptoms
Not on AATherapy or With
AA TherapyNot on AATherapy
On 1 AA Drug(BB Preferred) On $2 AA Drugs
PCI CABG PCI CABG PCI CABG PCI CABG
Low Disease Complexity (e.g., Focal Stenoses, SYNTAX #22)
16. n Low-risk findings on noninvasive testingn No diabetes
M (4) M (5) M (5) M (5) M (6) M (6) A (7) A (7)
17. n Intermediate- or high-risk findings onnoninvasive
testing
n No diabetes
M (6) A (7) A (7) A (7) A (7) A (8) A (8) A (8)
18. n Low-risk findings on noninvasive testingn Diabetes
present
M (4) M (6) M (5) M (6) M (6) A (7) A (7) A (8)
19. n Intermediate- or high-risk findings onnoninvasive
testing
n Diabetes present
M (6) A (7) M (6) A (8) A (7) A (8) A (7) A (9)
Intermediate or High Disease Complexity (e.g. Multiple Features
of Complexity as Noted Previously, SYNTAX >22)
20. n Low-risk findings on noninvasive testingn No diabetes
M (4) M (6) M (4) A (7) M (5) A (7) M (6) A (8)
21. n Intermediate- or high-risk findings onnoninvasive
testing
n No diabetes
M (5) A (7) M (6) A (7) M (6) A (8) M (6) A (9)
22. n Low-risk findings on noninvasive testingn Diabetes
present
M (4) A (7) M (4) A (7) M (5) A (8) M (6) A (9)
23. n Intermediate- or high-risk findings onnoninvasive
testing
n Diabetes present
M (4) A (8) M (5) A (8) M (5) A (8) M (6) A (9)
The number in parentheses next to the rating reflects the median
score for that indication.
A indicates appropriate; AA, antianginal; BB, beta blockers;
CABG, coronary artery bypass graft; M, may be appropriate; PCI,
percutaneous coronary intervention; and SYNTAX, Synergy betweenPCI
with Taxus and Cardiac Surgery trial.
Patel et al. J A C C V O L . 6 9 , N O . 1 7 , 2 0 1 7
AUC for Coronary Revascularization in Patients With SIHD M A Y 2
, 2 0 1 7 : 2 2 1 2 – 4 12226
first modality to assess ambiguous left main severity, andthe
criteria for a significant stenosis are the same as fornon–left
main stenosis (21,36,37).
Section 2. Tables 2.1 and 2.2 SIHD With Prior CABG
Patients with prior CABG surgery can present with a widespectrum
of disease progression. This includes thedevelopment of new
obstructive disease in coronary ar-teries not bypassed in the first
operation, new stenoses inexisting bypass grafts, and territory
previously bypassedbut jeopardized again because of graft
occlusion. Devel-oping indications inclusive of all of these
anatomic pos-sibilities would be impractical. Accordingly, the
writingcommittee adopted a more compact construct based onthe
presence of a significant stenosis in a bypass graft ornative
coronary artery supplying 1, 2, or 3 distinctvascular territories
roughly corresponding to the terri-tories of the 3 main coronary
arteries. As in patientswithout prior CABG, the indications
included an assess-ment of risk based on noninvasive testing (low
versusintermediate or high risk).
Evaluation of the severity and physiological signifi-cance of a
stenosis in saphenous vein grafts (SVG) can
be particularly challenging because of the usual markedsize
difference between the SVG and native artery.Although FFR
measurements are well-validated innative vessels, data on the use
of FFR in vein grafts arelimited (38). After CABG surgery, the
bypass conduitshould act in a similar fashion to the native,
low-resistance epicardial vessel. However, the assessmentof
ischemia due to a stenosis in a vein graft is compli-cated by
several features, which include: 1) the poten-tial for competing
flow (and pressure) from both thenative and conduit vessels; 2) the
presence of collateralsfrom longstanding native coronary occlusion;
and 3) thepotential for microvascular abnormalities due toischemic
fibrosis and scarring, pre-existing or bypasssurgery–related
myocardial infarction, or chronic low-flow ischemia. Despite these
complicating features, thetheory of FFR should apply equally to
both a lesion inan SVG to the right coronary artery feeding a
normalmyocardial bed and a lesion in the native right coro-nary.
However, if the native and collateral supplyare sufficiently large,
the FFR across an SVG stenosiscould be normal. FFR measurements may
be mostuseful in the setting of an occluded bypass graft to a
-
TABLE 1.4 Left Main Coronary Artery Stenosis
Appropriate Use Score (1–9)
Left Main Disease
Indication
Asymptomatic Ischemic Symptoms
Not on AATherapy or With
AA TherapyNot on AATherapy
On 1 AA Drug(BB Preferred) On $2 AA Drugs
PCI CABG PCI CABG PCI CABG PCI CABG
24. n Isolated LMCA diseasen Ostial or midshaft stenosis
M (6) A (8) A (7) A (8) A (7) A (9) A (7) A (9)
25. n Isolated LMCA diseasen Bifurcation involvement
M (5) A (8) M (5) A (8) M (5) A (9) M (6) A (9)
26. n LMCA diseasen Ostial or midshaft stenosisn Concurrent
multivessel diseasen Low disease burden (e.g., 1–2 additional
focal
stenoses, SYNTAX score #22)
M (6) A (8) M (6) A (9) A (7) A (9) A (7) A (9)
27. n Ostial or midshaft stenosisn Concurrent multivessel
diseasen Intermediate or high disease burden (e.g., 1–2
additional bifurcation stenosis, long stenoses,SYNTAX score
>22)
M (4) A (9) M (4) A (9) M (4) A (9) M (4) A (9)
28. n LMCA diseasen Bifurcation involvementn Low disease burden
in other vessels (e.g., 1–2
additional focal stenosis, SYNTAX score #22)
M (4) A (8) M (5) A (8) M (5) A (9) M (6) A (9)
29. n LMCA diseasen Bifurcation involvementn Intermediate or
high disease burden in other
vessels (e.g., 1–2 additional bifurcation ste-nosis, long
stenoses, SYNTAX score >22)
R (3) A (8) R (3) A (9) R (3) A (9) R (3) A (9)
The number in parentheses next to the rating reflects the median
score for that indication.
A indicates appropriate; AA, antianginal; BB, beta blockers;
CABG, coronary artery bypass graft; LMCA, left main coronary
artery; M, may be appropriate; PCI, percutaneous
coronaryintervention; R, rarely appropriate; and SYNTAX, Synergy
between PCI with Taxus and Cardiac Surgery trial.
J A C C V O L . 6 9 , N O . 1 7 , 2 0 1 7 Patel et al.M A Y 2 ,
2 0 1 7 : 2 2 1 2 – 4 1 AUC for Coronary Revascularization in
Patients With SIHD
2227
native artery with an intermediate-severity stenosis.FFR
measurements in bypass grafts are less well-validated and should
thus be interpreted with caution.
Two tables are presented for the rating of patients withprior
CABG depending on the patency of an existing in-ternal mammary
artery (IMA) graft. IMAs have a greaterlong-term patency rate than
SVGs—typically >90% after10 years (39,40). Accordingly, use of
the IMA as a conduitin CABG surgery has steadily increased. Current
use is98%, as reported in the Society of Thoracic Surgeons
na-tional database, and use of the IMA as a conduit is 1 of
thequality metrics in their composite score. Because of thecurrent
high use of the IMA, the writing committee feltthere were too few
patients to consider a separate cate-gory consisting of patients
who only had SVGs used intheir first operation, although a few such
patients mayexist. Moreover, the writing committee did not
developany scenarios where the initial operation consisted ofonly
bypass grafts to the circumflex and right coronaryartery in the
absence of LAD disease. The patency andlongevity of the IMA as a
bypass graft was felt by thewriting committee to be an important
decision point inthe indication development, as many cardiovascular
sur-geons are hesitant to perform a second bypass operation
in the presence of a patent and fully functional IMA
graft,especially to the LAD. The path of the IMA, particularly ifit
courses medially or is adherent to the back of the ster-num, may be
at greater risk during sternal re-entry, withadverse consequences
even if the IMA-grafted vessel isregrafted. For Table 2.1., it is
assumed that the LAD wassignificantly diseased at the time of the
original opera-tion. Therefore, if the IMA to the LAD is no longer
patentor is severely diseased, it is assumed that the native LADis
also severely diseased or occluded.
Section 3. Table 3.1 SIHD Undergoing Procedures for
WhichCoronary Revascularization May Be Considered
In an effort to capture common clinical scenarios that arenot
well-represented in guidelines, the writing groupdeveloped
indications for preoperative revascularizationin patients being
evaluated for renal transplantation orstructural heart procedures.
The writing committeerecognized that pre-operative
revascularization is some-times requested before transplantation of
other organs,but there is insufficient experience or data
fromcontrolled studies upon which to develop meaningfulscenarios.
These scenarios do not capture all possibleclinical situations, but
were felt to capture the majority of
-
TABLE 2.1 IMA to LAD Patent and Without Significant Stenoses
Appropriate Use Score (1–9)
Indication
Asymptomatic Ischemic Symptoms
Not on AATherapy or With
AA TherapyNot on AATherapy
On 1 AA Drug(BB Preferred) On $2 AA Drugs
PCI CABG PCI CABG PCI CABG PCI CABG
Stenosis Supplying 1 Territory Disease (Bypass Graft or Native
Artery) to Territory Other Than Anterior
30. n Low-risk findings on noninvasive testing R (3) R (1) R (3)
R (2) M (6) R (3) A (7) M (4)
31. n Intermediate- or high-risk findings onnoninvasive
testing
M (5) R (3) M (5) R (3) A (7) M (4) A (8) M (5)
32. n No stress test performed or, if performed, theresults are
indeterminate
n FFR of stenosis #0.80*
M (4) R (3) M (4) R (3) M (6) M (4) A (8) M (5)
Stenoses Supplying 2 Territories (Bypass Graft or Native Artery,
Either 2 Separate Vessels or Sequential Graft Supplying 2
Territories) Not Including AnteriorTerritory
33. n Low-risk findings on noninvasive testing R (3) R (2) M (4)
R (3) M (6) R (3) A (7) M (5)
34. n Intermediate- or high-risk findings onnoninvasive
testing
M (5) R (3) M (5) M (4) A (7) M (5) A (8) M (6)
The number in parentheses next to the rating reflects the median
score for that indication. *iFR measurements with appropriate
normal ranges may be substituted for FFR.
A indicates appropriate; AA, Antianginal; BB, beta blockers;
CABG, coronary artery bypass graft; FFR, fractional flow reserve;
iFR, instant wave-free ratio; IMA, internal mammary artery; LAD,
leftanterior descending coronary artery; M, may be appropriate;
PCI, percutaneous coronary intervention; and R, rarely
appropriate.
Patel et al. J A C C V O L . 6 9 , N O . 1 7 , 2 0 1 7
AUC for Coronary Revascularization in Patients With SIHD M A Y 2
, 2 0 1 7 : 2 2 1 2 – 4 12228
common clinical situations. If patients have an acutecoronary
syndrome, the writing group felt they should
be rated according to the AUC for acute coronary syn-
drome. For many of these patients, symptoms may bedifficult to
attribute to myocardial ischemia; thus, theindications used in this
table provide only anatomic andnoninvasive test findings for
review. Note that for pa-tients being evaluated before a
percutaneous valve pro-cedure, the option for CABG surgery is
blocked out, as it isassumed such patients have clinical factors
making theirrisk of surgery prohibitively high.
7. DISCUSSION
The AUC are intended to inform clinicians, patients, andhealth
policy makers about the reasonable use of tech-nologies to help
improve patient symptoms and healthoutcomes. Since 2005, the
American College of Cardiol-ogy, along with its professional
partners, has worked toprovide criteria for both invasive and
noninvasive testingand selected treatments, with the intention of
furtherexpanding the AUC portfolio.
The 2017 Appropriate Use Criteria for Revascularizationin
Patients With Stable Ischemic Heart Disease is theculmination of
approximately 2 years of review and revi-sion to the existing AUC.
In response to comments frommultiple stakeholders, the current AUC
has severalimportant changes (41). First, this document will use
thenew terms “appropriate care,” “may be appropriate care,”and
“rarely appropriate care,”which were described in theupdated AUC
methodology paper (2). Second, the compo-sition of the rating panel
was changed slightly to include
5 cardiac surgeons, 5 interventional cardiologists, 6
cardi-ologists not directly involved with performing
revascu-larization, and 1 outcomes researcher. Third, the
newcriteria stratify symptoms into 2 general group-s—asymptomatic
and ischemic symptoms—to be inclusiveof the spectrum of complaints
that may occur frommyocardial ischemia. Furthermore, because of the
varietyof symptoms that may indicate myocardial ischemia,
in-dividual patient variation in how they are described,
andobserver variability in the assessment of symptomseverity, the
writing group chose to abandon the CanadianCardiac Society
classification. However, the currentcriteria continue to emphasize
the use of more objectivemeasures of ischemia within indications to
stratify pa-tients into low-risk or intermediate-/high-risk
findings, asdescribed in the SIHD guideline. Fourth, the
scenariosexpand the use of intracoronary physiological
testing,mainly with FFR. Fifth, the structure of the AUC
tablesconcerning the use of antianginal therapy has changed
toreflect typical practice patterns rating patients on the basisof
no antianginal therapy, use of 1 antianginal drug, or useof 2
ormore antianginal drugs. As in earlier documents, it isassumed
that all patients are being treated with guideline-directed medical
therapies to reduce risk. Finally, in aneffort to capture patients
who have not previously beencategorized, the current AUC also rate
coronary revascu-larization in patients being considered for renal
trans-plantation and percutaneous valve procedures.
Review of the ratings demonstrate some themesaround
revascularization of patients with SIHD that areconsistent with
existing clinical practice guidelines. Ingeneral, in patients with
a low burden of coronary disease
-
TABLE 2.2 IMA to LAD Not Patent
Appropriate Use Score (1–9)
Indication
Asymptomatic Ischemic Symptoms
Not on AATherapy or With
AA TherapyNot on AATherapy
On 1 AA Drug(BB Preferred) On $2 AA Drugs
PCI CABG PCI CABG PCI CABG PCI CABG
Stenosis Supplying 1-Territory Disease (Bypass Graft or Native
Artery)–Anterior (LAD) Territory
35. n Low-risk findings on noninvasive testing M (4) R (3) M (5)
R (3) M (6) M (4) A (7) M (5)
36. n Intermediate- or high-risk findings onnoninvasive
testing
M (6) M (4) M (6) M (4) A (7) M (5) A (8) M (6)
37. n No stress test performed or, if performed, theresults are
indeterminate
n FFR of stenosis #0.80*
M (5) M (4) M (6) M (4) A (7) M (5) A (8) M (6)
Stenoses Supplying 2 Territories (Bypass Graft or Native Artery,
Either 2 Separate Vessels or Sequential Graft Supplying 2
Territories) LAD Plus Other Territory
38. n Low-risk findings on noninvasive testing M (5) M (4) M (6)
M (4) A (7) M (5) A (7) M (6)
39. n Intermediate- or high-risk findings onnoninvasive
testing
M (6) M (5) A (7) M (6) A (7) A (7) A (8) A (8)
Stenoses Supplying 3 Territories (Bypass Graft or Native
Arteries, Separate Vessels, Sequential Grafts, or Combination
Thereof) LAD Plus 2 Other Territories
40. n Low-risk findings on noninvasive testing M (5) M (5) M (6)
M (5) M (6) M (6) A (7) A (7)
41. n Intermediate- or high-risk findings onnoninvasive
testing
A (7) A (7) A (7) A (7) A (7) A (7) A (8) A (8)
The number in parentheses next to the rating reflects the median
score for that indication. *iFR measurements with appropriate
normal ranges may be substituted for FFR.
A indicates appropriate; AA, Antianginal; BB, beta blockers;
CABG, coronary artery bypass graft; FFR, fractional flow reserve;
iFR, instant wave-free ratio; IMA, internal mammary artery; LAD,
leftanterior descending coronary artery; M, may be appropriate;
PCI, percutaneous coronary intervention; and R, rarely
appropriate.
J A C C V O L . 6 9 , N O . 1 7 , 2 0 1 7 Patel et al.M A Y 2 ,
2 0 1 7 : 2 2 1 2 – 4 1 AUC for Coronary Revascularization in
Patients With SIHD
2229
(e.g., single-vessel disease), low-risk findings on nonin-vasive
testing, and/or no antianginal therapy, revascu-larization by PCI
or CABG surgery for care is felt to berarely appropriate as the
initial step. As disease burdenprogresses through 2-vessel to
3-vessel and left maindisease, revascularization by PCI or CABG
frequently be-comes rated as “may be appropriate care” or
“appropriatecare,” with CABG surgery consistently rated as
“appro-priate care” for intermediate or high disease
complexity(SYNTAX $22) even in patients with ischemic symptomswho
are not on antianginal therapy. Of note, CABG sur-gery was
consistently rated as “appropriate care” and PCIas “rarely
appropriate care” for left main bifurcation dis-ease with
intermediate or high disease burden in othervessels.
Repeat CABG surgery was felt to be rarely appropriatein patients
with a functional patent IMA to the LAD in allbut 1 indication,
with both PCI and CABG being rated aseither “may be appropriate
care” or “appropriate care” inthe other indications, reflecting the
complex and indi-vidualized decision making required in these
patients.With the exception of a few specific scenarios in
asymp-tomatic patients with a low disease burden,
revasculari-zation options were considered as “may be
appropriatecare” or “appropriate care” options. Although not
directlyrated, the use of fractional flow reserve for evaluation
ofrenal transplant patients may be considered and will beaddressed
in future revascularization documents. Revas-cularization by PCI
was considered appropriate care for
the majority of patients being evaluated before a percu-taneous
valve procedure.
Application of Criteria
There are many potential applications for AUC, includingtheir
adoption by Centers for Medicare & Medicaid Ser-vices
regulators as a means of evaluating care. Clinicianscan use the
ratings for decision support or as an educa-tional tool when
considering the need for revasculariza-tion. Moreover, these
criteria can be used to facilitatediscussions with patients and/or
referring physiciansabout the need for revascularization. The
original intentof the AUC was to provide a tool to identify
patterns ofcare, including both the overuse and underuse of
variousservices. In fact, some of the initial publications related
toAUC identified underuse and the consequences ofunderuse rather
than overuse of services (42,43). Facil-ities have used these
criteria to design protocols to facil-itate the appropriate care of
patients. Some payers haveadopted the AUC for use in the
preauthorization of pro-cedures or retrospectively for quality
reports. Althoughthe AUC were never intended to determine payment
inindividual patients, some payers have adopted the AUCfor this
purpose. The desire of payers to control costs isunderstood, but it
should be in the context of developingrational payment management
strategies to ensure theirmembers receive necessary, beneficial,
and cost-effectivecardiovascular care, rather than for other
purposes. It isexpected that services performed for “appropriate”
or
-
TABLE 3.1 Stable Ischemic Heart Disease Undergoing Procedures
for Which Coronary Revascularization May Be Considered
Appropriate Use Score (1–9)
Indication
Asymptomatic Ischemic Symptoms
Not on AA Therapyor With AATherapy Not on AA Therapy
On 1 AA Drug(BB Preferred) On $2 AA Drugs
PCI CABG PCI CABG PCI CABG PCI CABG
Patients Undergoing Renal Transplantation, No Diabetes
42. n One- or two-vessel CAD, no proximal LAD involvement, with
low-risk noninvasivefindings
R (3) R (2) M (4) R (3) M (6) M (4) A (7) M (5)
43. n One- or two-vessel CAD, no proximal LAD involvement, with
intermediate- or high-risknoninvasive findings
M (5) M (4) M (6) M (4) A (7) M (5) A (8) M (6)
44. n One- or two-vessel CAD, including proximal LAD, with
low-risk noninvasive findings M (5) M (4) M (6) M (5) M (6) M (6) A
(8) A (7)
45. n One- or two-vessel CAD, including proximal LAD, with
intermediate- or high-risknoninvasive findings
M (6) M (6) A (7) A (7) A (7) A (7) A (8) A (8)
46. n Left main and/or three-vessel disease, with intermediate-
or high-risk noninvasivefindings (e.g., SYNTAX #22)
M (6) A (7) A (7) A (7) A (7) A (7) A (8) A (8)
47. n Left main and/or three-vessel disease, with intermediate-
or high-risk noninvasivefindings (e.g., SYNTAX >22)
M (5) A (7) M (6) A (8) M (6) A (8) M (6) A (9)
Patients Undergoing Renal Transplantation, Diabetes Present
48. n One- or two-vessel CAD, no proximal LAD involvement, with
low-risk noninvasivefindings
R (3) R (3) M (4) R (3) M (5) M (4) A (7) M (6)
49. n One- or two-vessel CAD, no proximal LAD involvement, with
intermediate- or high-risknoninvasive findings
M (5) M (4) M (5) M (4) M (6) M (5) A (7) A (7)
50. n One- or two-vessel CAD, including proximal LAD, with
low-risk noninvasive findings M (5) M (5) M (5) M (6) M (5) A (7) A
(7) A (7)
51. n One- or two-vessel CAD, including proximal LAD, with
intermediate- or high-risknoninvasive findings
M (6) M (6) M (6) A (7) M (6) A (7) A (7) A (8)
52. n Left main and/or three-vessel disease, with intermediate-
or high-risk noninvasivefindings (e.g., SYNTAX #22)
M (6) A (8) M (6) A (8) M (6) A (8) A (7) A (9)
53. n Left main and/or three-vessel disease, with intermediate-
or high-risk noninvasivefindings (e.g., SYNTAX >22)
M (5) A (8) M (5) A (8) M (5) A (9) M (5) A (9)
Patient Who Will Undergo a Percutaneous Valve Procedure (TAVR,
MitraClip, Others)
54. n One- or two-vessel CAD, no proximal LAD involvement, with
low-risk noninvasivefindings
M (4) M (4) M (6) A (8)
55. n One- or two-vessel CAD, no proximal LAD involvement, with
intermediate- or high-risknoninvasive findings
A (7) A (7) A (7) A (8)
56. n One- or two-vessel CAD, including proximal LAD, with
low-risk noninvasive findings M (6) M (6) A (7) A (8)
57. n One- or two-vessel CAD, including proximal LAD, with
intermediate- or high-risknoninvasive findings
A (7) A (7) A (8) A (9)
58. n Left main and/or three-vessel disease, with intermediate-
or high-risk noninvasivefindings (e.g., SYNTAX #22)
A (8) A (8) A (8) A (9)
59. n Left main and/or three-vessel disease, with intermediate-
or high-risk noninvasivefindings (e.g., SYNTAX >22)
A (7) A (7) A (8) A (8)
The number in parentheses next to the rating reflects the median
score for that indication.
A indicates appropriate; AA, Antianginal; BB, beta blockers;
CABG, coronary artery bypass graft; CAD, coronary artery disease;
LAD, left anterior descending coronary artery; M, may be
appropriate; PCI, percutaneous coronary intervention;R, rarely
appropriate; SYNTAX, Synergy between PCI with Taxus and Cardiac
Surgery trial; and TAVR, transcatheter aortic valve
replacement.
Patelet
al.JACC
VOL.69,NO.17,2017
AUCfor
CoronaryRevascularization
inPatients
With
SIHD
MAY
2,2017:2
212–41
2230
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J A C C V O L . 6 9 , N O . 1 7 , 2 0 1 7 Patel et al.M A Y 2 ,
2 0 1 7 : 2 2 1 2 – 4 1 AUC for Coronary Revascularization in
Patients With SIHD
2231
“may be appropriate” indications will receive reim-
bursement. In contrast, services performed for
“rarelyappropriate” indications should be justified by
additionaldocumentation to justify payment because of the
uniquecircumstances or the clinical profile that must exist insuch
a patient. It is critical to emphasize that the writinggroup,
technical panel, Appropriate Use Criteria TaskForce, and clinical
community do not believe a rating of“may be appropriate” is
justification to deny reimburse-ment for revascularization. Rather,
“may be appropriate”ratings are those in which the available data
vary andmany other factors exist that may affect the decision
toperform or not perform revascularization. The opinions ofthe
technical panel often varied for these indications,reflecting that
additional research is needed.
The writing group recognizes the need to align thecollection of
clinical data required for the determinationof appropriate use with
appropriate methods to reducethe burden of data collection. To this
end, the NCDRCathPCI Registry group has been engaged in a
parallelprocess to ensure that needed data elements are
incor-porated into the Registry. The criteria will also be
eval-uated for collection by the Society for Thoracic
Surgeonsregistry. Incorporating fields to identify patients who
arenot felt to be candidates for PCI or CABG surgery hasbeen
suggested to ensure proper mapping of the AUC inthe course of
medical decision making. The writingcommittee believes the key step
to ensuring that theAUC are iterated and continually improved is
the use ofa feedback cycle of data between current clinical
practiceand the Registry. The writing group also believes thatthe
mapping of the data elements on the NCDR CathPCIRegistry data
collection from the AUC should be
transparent for all providers to review and implementlocal
systems of care.
In conclusion, this document represents the currentunderstanding
of the clinical benefit of coronary revascu-larization with respect
to health outcomes and survival.These criteria have been developed
through the AUC pro-cess and alignment with the evidence and
recommenda-tions from clinical practice guidelines. This is
intended toprovide a practical guide to clinicians and patients
whenconsidering revascularization. As with all AUC, some ofthese
ratings will require research and further evaluationto provide the
greatest information and benefit to clinicaldecision making. We
anticipate that the utility and abilityof these criteria to improve
the quality of care will bemeasured by the overall use and adoption
of the criteria.With each update, the AUC for coronary
revascularizationin SIHD have becomemore refined and specific,
while areasfor continued focus and research have been
identified.
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, Director,
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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