• The New 2017 Appropriate Use Criteria for Coronary Revascularization (Part I)

    June 23, 2017

    By: Gregory J. Dehmer, MD, MSCAI

    SCAI has again collaborated with the American College of Cardiology, the American Heart Association, the Society of Thoracic Surgery and other organizations to develop appropriate use criteria (AUC) for coronary artery revascularization. The first such document was published in 2009, an update was published in 2012 and recently the latest version of the AUC was released. For the latest version, two documents were developed, one specific for acute coronary syndromes (ACS) and the other specific for stable ischemic heart disease (SIHD)1, 2. This was done primarily so the AUC for ACS could be released earlier and maintain alignment with the latest update of the STEMI/PCI guideline3. Common to both documents is the use of the new terminology for classifying appropriateness: Appropriate, May Be Appropriate and Rarely Appropriate as defined in the latest AUC methodology document4. Use of the prior terms, especially the classification designated “inappropriate” led to many concerns among operators and misunderstandings among administrators and especially in the lay press.

    The development of the AUC has several stages. First, a writing committee is formed consisting of physicians nominated by their professional organizations. For the new AUC, the writing group was composed of 3 interventional cardiologists (all SCAI fellows), 2 cardiac surgeons and 2 cardiologists not directly involved with the performance of revascularization procedures. After an extensive review of the literature and especially new data since the prior AUC, the writing group develops the structure for the AUC and the specific scenarios for classification. These are sent for external review and the comments received used to modify the scenarios as needed. Second, a rating panel is formed from physicians nominated by their professional organizations. To address a criticism of the prior document, the new rating panel was balanced with 5 interventional cardiologists (all SCAI fellows), 5 cardiac surgeons and 5 cardiologists not directly involved with the performance of revascularization procedures. Each member of the rating panel classifies each scenario individually before a face-to-face group meeting is held to discuss summary data from the first round of ratings. A second round of ratings is then completed by each member of the rating panel. Finally, the document is drafted combining the background information, assumptions and ratings. Once completed and before publication, the document is sent to all of the professional organizations involved for review and approval.


    The AUC for ACS

    1. The major change is the inclusion of ratings for the treatment of non-culprit arteries in patients presenting with STEMI. The 2015 Guideline Focused Update moved treatment of non-culprit arteries from Class III: Harm to Class IIb3.

    2. Scenarios for non-culprit artery PCI were developed for treatment during the same procedure immediately following treatment of the culprit artery or treatment during the same hospitalization. Once the patient leaves the hospital, they are assumed to be stable and treatment of additional non-culprit arteries should be classified using the SIHD AUC.

    3. Treatment of one or more non-culprit arteries during the same procedure was graded as appropriate in the presence of cardiogenic shock persisting after treatment of the culprit artery. In stable patients treatment during the same procedure was graded as may be appropriate in the presence of one or more severe (≥70%) stenoses or intermediate stenoses (50%–70%). 

    4. Treatment of a non-culprit artery later but during the same hospitalization was graded as appropriate in the presence of a severe stenosis with spontaneous or easily provoked ischemic symptoms or in asymptomatic patients with ischemic findings on noninvasive testing. A grade of may be appropriate was assigned in asymptomatic patients with a severe stenosis in the absence of any additional noninvasive testing.

    5. The only rarely appropriate rating occurred in a scenario where an asymptomatic patient with an intermediate severity stenosis (50%–70%) in a non-culprit artery undergoes PCI later during their hospitalization without any additional testing to demonstrate ischemia. However, if an FFR measurement is performed in the non-culprit artery with an intermediate stenosis and is ≤ 0.80, performing a PCI moves to an appropriate rating.


    Summary

    AUCs are becoming more important as there continues to be a shift from a volume-based to value-based reimbursement scheme. The new AUC for ACS was developed to match the latest guidelines and literature on the treatment of patients with STEMI and should help clinicians ensure their patients are receiving proper care. A diagrammatic representation of the new AUC for ACS from the original publication in JACC1 is presented below and is suitable for posting in the cath lab.

    In Part II, which will be featured next month, we will focus on the new AUC for patients with SIHD. 


    References

    1. Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, Smith PK. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 appropriate use criteria for coronary revascularization in patients with acute coronary syndromes: 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 the Society of Thoracic Surgeons. J Am Coll Cardiol 2017;69:570–591.

    2. Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, Smith PK. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria for coronary revascularization in patients with 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. J Am Coll Cardiol 2017;69:2212–2241.

    3. Levine GN, O’Gara PT, Bates ER, Blankenship JC, Kushner FG, Ascheim DD, Bailey SR, Bittl JA, Brindis RG, Casey DE Jr, Cercek B, Chambers CE, Chung MK, de Lemos JA, Diercks DB, Ellis SG, Fang JC, Franklin BA, Granger CB, Guyton RA, Hollenberg SM, Khot UN, Krumholz HM, Lange RA, Linderbaum JA, Mauri L, Mehran R, Morrow DA, Moussa ID, Mukherjee D, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Ting HH, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2016;67:1235–1250.

    4. Hendel RC, Patel MR, Allen JM, Min JK, Shaw LJ, Wolk MJ, Douglas PS, Kramer CM, Stainback RF, Bailey SR, Doherty JU, Brindis RG. Appropriate use of cardiovascular technology: 2013 ACCF appropriate use criteria methodology update: a report of the American College of Cardiology Foundation appropriate use criteria task force. J Am Coll Cardiol 2013;61:1305-1317.