ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update
Why the study?
An update of the appropriate use criteria for coronary revascularization was needed due to significant changes in medical literature and gaps from prior criteria.
When is coronary revascularization appropriate across varying clinical presentations of coronary artery disease?
Key Points
- To update and refine appropriate use criteria for coronary revascularization across diverse clinical scenarios based on recent medical evidence and practice gaps.
- Engaged a multi-society expert panel to reassess clinical scenarios incorporating symptom status, extent of medical therapy, noninvasive risk stratification, and coronary anatomy.
- Scored scenarios using a standardized 1 to 9 scale to categorize procedures as appropriate (7–9), uncertain (4–6), or inappropriate (1–3).
- Revascularization remained appropriate for patients presenting with acute coronary syndromes or combinations of severe symptoms and documented ischemia.
- Revascularization was rated unfavorably for asymptomatic patients or those with low-risk noninvasive test findings receiving minimal medical therapy.
- Coronary artery bypass grafting remained an appropriate treatment for high-burden coronary artery disease, with percutaneous coronary intervention identified as having a role in select high-burden presentations.
Structured PICO
When is coronary revascularization appropriate across varying clinical presentations of coronary artery disease?
P
Population
Patients considered for coronary revascularization (including those with acute coronary syndromes, high burden of coronary artery disease, and asymptomatic presentations)
I
Intervention
Coronary revascularization (coronary artery bypass grafting or percutaneous coronary intervention)
O
Outcome
Appropriateness of revascularization based on technical panel scoring (scale 1 to 9) across 180 clinical scenarios
This focused update outlines the appropriate use criteria for coronary revascularization across 180 clinical scenarios to improve physician decision-making.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“So technically speaking, if you did a nonculprit vessel in a stable patient the way current appropriate use criteria are structured, it would be graded as inappropriate. But the latest guidelines give it a Class 2b recommendation. So practitioners are kind of caught in a little bit of a bind here.”
“So if something's not rated as appropriate, colloquially speaking, you view that to be inappropriate. But the reality is there may be things that are [clinically] appropriate but may not be rated 'appropriate'. And that's why there's so much confusion in this area.”
GWGregg W. StoneInterventional cardiologist, Columbia University Medical Center
“The recommendations for PCI don't exactly follow the SYNTAX data presented thus far and don't take into account the data from the MAIN-COMPARE and PRECOMBAT trials, but it's still a step in the right direction.”
Implication
Refines revascularization indications in coronary disease; extends prior AUC with expert consensus but leaves open prospective validation.
Abstract
The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an update of the appropriate use criteria (AUC) for coronary revascularization frequently considered. In the initial document, 180 clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. This update provides a reassessment of clinical scenarios the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document, and the definition of appropriateness was unchanged. The technical panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate and likely to improve patients' health outcomes or survival. Scores of 1 to 3 indicate revascularization is considered inappropriate and unlikely to improve health outcomes or survival. Scores in the mid-range (4 to 6) indicate a clinical scenario for which the likelihood that coronary revascularization will improve health outcomes or survival is uncertain. In general, as seen with the prior AUC, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally,percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.
Discussion
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Cite This Study
Patel et al. (2012) conducted a review in Coronary Artery Disease. Coronary revascularization (CABG and PCI) was evaluated on Appropriateness of clinical scenarios scored from 1 to 9. Coronary revascularization remains appropriate for acute coronary syndromes and a high burden of coronary artery disease, but is viewed less favorably for asymptomatic or low-risk patients.