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 about the appropriateness of revascularization procedures. The committee acknowledges that these guidelines are not meant to be a substitute for clinical judgment. Even if the appropriateness of a revascularization is listed as "uncertain" this does not mean that a physician should not perform a PCI. Likewise, even if revascularization is deemed to be "appropriate" by the appropriate use criteria, 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).

”

Scenarios Where Revascularization was Deemed Either Appropriate or Inappropriate

STEMI

• Revascularization in STEMI patients greater than 12 hours from symptom onset who have no symptoms of ischemia or clinical instability was deemed inappropriate. 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 appropriate.

Stable Ischemia 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 appropriate.
• In patients who have not undergone a stress test, PCI was deemed to be appropriate 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 inappropriate.
• In patients who have not undergone a stress test who have severe symptoms and either an abnormal FFR or IVUS, revascularization is appropriate.

Stable Ischemia 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 the revascularization is appropriate.
• Revascularization was deemed inappropriate in patients on no or minimal medications who had low risk findings on non-invasive testing.
• There are many uncertain scenarios in this population.

PCI and CABG Among Patients with Advanced Coronary Artery Disease

• In general revascularization was deemed necessary in this population of patients.
• CABG was deemed to be appropriate in all the clinical scenarios.
• PCI was deemed to be appropriate in patients with 2 vessel disease without involvement of the proximal LAD, and it was deemed uncertain in patients with 3 vessel disease.
• Among patients with left main disase and or left main disease plus multivessel disease, CABG was deemed to be appropriate. PCI was deemed not to be a reasonable approach and "unlikely to imporve the patient's health or survival".

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).