Appropriate use criteria for revascularization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Synonyms and keywords: AUC

Overview

The goal of the appropriate use criteria is to provide general guidance to both patients and clinicians regarding 'when' and 'how often' revascularization procedures should be done. This takes into consideration the available scientific evidences, the health care environment, the patient’s profile and a physician’s judgment. The committee acknowledges that these ratings are not meant to be a substitute for clinical judgment. Even if the appropriateness of a revascularization is listed as "rarely appropriate care" this does not mean that a physician should not perform a PCI. Likewise, even if revascularization procedure is rated as the "appropriate care", there may be mitigating circumstances that indicate PCI should not be undertaken. Rather than individual scenarios, the appropriate use criteria are meant to evaluate the overall patterns of care in different healthcare systems. If one system of care has, for instance, an 80% rate of appropriate use of revascularization whereas another system has a 40% appropriate use of revascularization, then perhaps this discrepancy should be evaluated further.

New Scoring System

Appropriate Care

Median Score 7 to 9

“

An appropriate option for management of this patient population due to benefits generally outweighing risks; effective option for individual care plans although not always necessary depending on physician judgment and patient specific preferences (i.e., procedure is generally acceptable and is generally reasonable for the indication).

”

May Be Appropriate Care

Median Score 4 to 6

“

At times an appropriate option for management of this patient population due to variable evidence or agreement regarding the benefits risks ratio, potential benefit based on practice experience in the absence of evidence, and/or variability in the population; effectiveness for individual care must be determined by a patient’s physician in consultation with the patient based on additional clinical variables and judgment along with patient preferences (i.e., procedure may be acceptable and may be reasonable for the indication).

”

Rarely Appropriate Care

Median Score 1 to 3

“

Rarely an appropriate option for management of this patient population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication).

”

Appropriate Use Ratings for Revascularization in Acute Coronary Syndromes

UA/NSTEMI

Cardiogenic shock

STEMI

Low risk features

Intermediate/High risk features

Appropriate Care

Primary perfusion

Thrombolytic therapy

May Be Appropriate Care

Appropriate Care

≤12 hours

≥12 hours

Asymptomatic

Evidence of HF, recurrent ischemia, or unstable ventricular arrhythmia

Appropriate Care

Severe HF, persistent ischemia, hemodynamic or electrical instability

Asymptomatic

Normal LVEF with 1-vessel disease

Depressed LVEF with 3-vessel disease

Appropriate Care

Appropriate Care

Rarely Appropriate Care

May Be Appropriate Care

Appropriate Care

Adapted from Journal of the American College of Cardiology

Clinical Scenarios

Acute Coronary Syndromes

• Revascularization in patients with UA/NSTEMI with low risk (TIMI score ≤ 2) was deemed as may be appropriate care, while those with an intermediate risk (TIMI score 3-4), it was deemed the appropriate care.
• Revascularization in STEMI patients greater than 12 hours from symptom onset who have no symptoms of ischemia or clinical instability was deemed to be the rarely appropriate care. Likewise the need for immediate angiography in these patients was deemed unnecessary.
• Revascularization of the non-culprit artery in STEMI patients who are not clinically unstable was deemed the appropriate care.

Stable Ischemic Heart Disease without Prior CABG

• High risk findings on non invasive testing, greater symptoms, a large burden of disease in the native vessels increases the likelihood that the revascularization is the appropriate care.
• In assymptomatic patients who have not undergone a stress test, PCI was deemed to be the rarely appropriate care in the presence of 1 or 2 vessel disease with no involvement of the LAD.
• In patients who have not undergone a stress test, PCI was deemed to be the appropriate care in the presence of 1 or 2 vessel disease with or without involvement of the proximal LAD if class III or IV anginal symptoms were present. The amount of medical therapy was not included in their consideration of appropriateness.
• In patients who have not undergone a stress test who have an intermediate stenoses, revascularization without further documentation of the significance of the stenosis by either FFR or IVUS was deemed to be the rarely appropriate care.
• In patients who have not undergone a stress test who have severe symptoms and either an abnormal FFR or IVUS, revascularization is the appropriate care.

Stable Ischemic Heart Disease with Prior CABG

• High risk findings on non invasive testing, greater symptoms, a large burden of disease in the native vessels or bypass conduits increases the likelihood that revascularization will be the appropriate care.
• In patients receiving no or minimal anti-ischemic medications who had low risk findings on non-invasive testing, revasculaization is rarely the appropriate care. In this population, there are many scenarios where revascularization was deemed may be appropriate care, reflecting their higher complexity, higher risk, and the limited availability of published evidence regarding management outcome.

PCI and CABG Among Patients With Multivessel CAD

• In general revascularization was deemed necessary in this population of patients
• CABG was deemed to be the appropriate care in all the clinical scenarios
• PCI was deemed to be the appropriate care in patients with:
  • 2-vessel disease with the involvement of the proximal LAD
  • 3-vessel disease with a low CAD burden (i.e., 3 focal stenoses, low SYNTAX score)
• PCI may be appropriate care in patients with:
  • Isolated left main stenosis
  • Left main stenosis and additional CAD with low CAD burden (i.e., 1-2-vessel additional involvement, low SYNTAX score)
  • 3-vessel disease with a high CAD burden (i.e., 3 focal stenoses, high SYNTAX score)
  • 3-vessel disease CAD with intermediate to high CAD burden (i.e., multiple diffuse lesions, chronic total occlusion (CTO), or high SYNTAX score)
• PCI is the rarely appropriate care in patients with:
  • Left main stenosis and additional CAD with intermediate to high CAD burden (i.e., 3-vessel involvement, presence of CTO, or high SYNTAX score)

Limitations

The AUC does not take into account the severity or morphology of lesions but relies upon symptoms, the results of exercise stress testing, the use of medications and simply the location of the lesion(s).