Multisociety Appropriate-Use Criteria Address Coronary Revascularization for ACS

December 22, 2016–The American College of Cardiology (ACC) announced the publication of an updated, multisociety appropriate use criteria (AUC) for performing coronary revascularization in patients with acute coronary syndromes (ACS). The document is available online in the Journal of the American College of Cardiology.

Manesh R. Patel, MD, who served as chair of the writing committee for the AUC document, commented in the ACC announcement, “This update provides a reassessment of clinical scenarios that the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision-making and ultimately lead to better patient outcomes.”

The AUC were produced by ACC, the American Association for Thoracic Surgery, the American Heart Association (AHA), American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons.

The document is part one of a two-part revision for coronary revascularization. An updated AUC for coronary revascularization in patients with stable ischemic heart disease will be released next year. Previously addressed in one document, this two-part format addresses the expanding clinical indications for coronary revascularization and seeks to align the subject matter with the most current ACC/AHA guidelines.

According to ACC's announcement, the AUC includes clinical scenarios developed to mimic patient presentations that may be encountered in everyday practice and information on symptom status, the presence of clinical instability or ongoing ischemic symptoms, previous reperfusion therapy, risk level as assessed by noninvasive testing, fractional flow reserve testing, and coronary anatomy. The clinical scenarios are scored to indicate whether revascularization is appropriate, may be appropriate, or is rarely appropriate for the clinical scenario presented.

As summarized in the AUC, there are 17 clinical scenarios developed by the writing committee and scored by an independent rating panel. Ten were identified as appropriate, six as may be appropriate, and one as rarely appropriate.

As with previous coronary revascularization AUC, revascularization in clinical scenarios with ST-segment elevation myocardial infarction and non–ST-segment elevation myocardial infarction were considered appropriate. Likewise, clinical scenarios with unstable angina and intermediate- or high-risk features were deemed appropriate. In addition, the management of nonculprit artery disease and the timing of revascularization are now rated.

ACC advised that the document can be used as a clinical tool to assist clinicians in evaluating therapies and can help to better inform patients about their treatment options. The society noted that it is important for patients to discuss revascularization and engage in shared decision-making with their provider to come to a decision on the best treatment plan. The writing committee also stresses that the criteria should be used as an overall guide and physicians should evaluate each case on an individual basis.