Focused Update Published on Appropriate Use Criteria for Revascularization

January 30, 2012—The American College of Cardiology announced the publication of updated appropriate use criteria that offer detailed guidance on when to use an invasive procedure to improve blood flow to the heart and how to choose the best procedure for each patient. The clinical scenarios affirm the role of revascularization for patients with acute coronary syndromes and significant symptoms.

The update, which was conducted by the American College of Cardiology Foundation, the Society for Cardiovascular Angiography and Interventions, the Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, is available online ahead of print in the Journal of the American College of Cardiology. The updated appropriate use criteria replace a previous set published in 2009.

“This document helps patients, physicians, and payers determine when it's reasonable to do a procedure that is intended to improve the patient's quality of life, health status, and long-term survival,” commented Manesh Patel, MD, lead author of the updated appropriate use criteria. “It can also assist patients and physicians with health-related discussions and shared decision-making, so that patients are confident they are getting the right procedures for them.”

New clinical data and gaps identified in data collection spurred the update of the appropriate use criteria. Dr. Patel stated, “This update provides a reassessment of clinical scenarios the writing group believed to be affected by significant changes in the medical literature or gaps from prior criteria. For example, publication of the SYNTAX trial called for the reexamination of clinical scenarios for multivessel coronary artery disease, and implementation efforts revealed a few scenarios not captured in the 2009 publication.”

Symptom status, extent of medical therapy, risk level as assessed by noninvasive testing and coronary anatomy all play a critical role in decision making. The appropriate use criteria scenarios were developed to mimic patient presentations encountered in everyday practice and to address the rational use of coronary revascularization in the delivery of high-quality care. Appropriate revascularization procedures can improve patients' clinical outcomes, whereas inappropriate revascularization exposes patients to unwarranted risk and increases costs to the health care system.

Coauthor Peter K. Smith, MD, said, “The new ratings that have changed percutaneous coronary interventions (PCI) from inappropriate to uncertain for low burden left main disease, and from uncertain to appropriate for low burden three-vessel disease should result in careful selection of high-risk surgery patients for PCI. Surgeons and cardiologists will now work together to maximize the benefit and minimize the risk for these patients who are at high risk for premature mortality.”

The updated criteria reaffirm that coronary artery bypass is appropriate for patient scenarios with coronary artery disease involving two vessels to include the proximal left anterior descending artery and all variations of three-vessel and left main coronary artery disease. PCI is appropriate in patients with coronary artery disease in all three heart arteries only if the severity of coronary artery disease burden is low. It is uncertain whether PCI is appropriate in patients with three-vessel coronary artery disease and an intermediate-to-high disease burden. The appropriateness of PCI is also deemed uncertain in patients with blockages in the left main coronary artery alone or with blockages in other arteries and low coronary artery disease burden. However, PCI is considered inappropriate in patients with blockages in the left main coronary artery with intermediate to high disease burden, according to the new criteria.

"A rating of uncertain does not mean that it's not reasonable or should not be done,” advised Dr. Patel. "These are areas where we don't have definitive evidence and think more research is needed. Remember, the majority of medicine may be considered uncertain by this evidence standard for improvement in health status or longevity. That's where physicians apply their clinical experience and knowledge to patient care and patients express their wishes."