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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]
ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/ STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease
Revascularization to Improve Survival Compared With Medical Therapy (DO NOT EDIT)
| Anatomic Setting | COR | LOE |
|---|---|---|
| UPLM or complex CAD | ||
| CABG and PCI | I—Heart Team approach recommended | C |
| CABG and PCI | IIa—Calculation of STS and SYNTAX scores | B |
| UPLM | ||
| CABG | I | B |
| PCI | IIa - For SIHD when both of the following are present:
1) Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score of ≤ 22, ostial or trunk left main CAD) 2) Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality ≥ 5%) |
B |
| PCI | IIa—For UA/NSTEMI if not a CABG candidate | B |
| PCI | IIa—For STEMI when distal coronary flow is TIMI flow grade <3 and PCI can be performed more rapidly and safely than CABG | C |
| PCI | IIb—For SIHD when both of the following are present:1) Anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (e.g., low-intermediate SYNTAX score of <33, bifurcation left main CAD) 2) Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate—severe COPD, disability from prior stroke, or prior cardiac surgery; STS-predicted operative mortality >2%) | B |
| PCI | III: Harm—For SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG | B |
| 3-vessel disease with or without proximal LAD artery disease | ||
| CABG | I | B |
| IIa—It is reasonable to choose CABG over PCI in patients with complex 3-vessel CAD (e.g., SYNTAX score >22) who are good candidates for CABG. | B | |
| PCI | IIb—Of uncertain benefit | B |
| 2-vessel disease with proximal LAD artery disease | ||
| CABG | I | B |
| PCI | IIb—Of uncertain benefit | B |
| 2-vessel disease without proximal LAD artery disease | ||
| CABG | IIa—With extensive ischemia | B |
| CABG | IIb—Of uncertain benefit without extensive ischemia | C |
| CABG | IIb—Of uncertain benefit | B |
| 1-vessel proximal LAD artery disease | ||
| CABG | IIa—With LIMA for long-term benefit | B |
| PCI | IIb—With LIMA for long-term benefit | B |
| 1-vessel proximal LAD artery disease | ||
| CABG | III: Harm | B |
| PCI | III: Harm | B |
| LV dysfunction | ||
| CABG | IIa—EF 35% to 50% | B |
| CABG | IIb—EF <35% without significant left main CAD | B |
| PCI | Insufficient data | |
| Survivors of sudden cardiac death with presumed ischemia-mediated VT | ||
| CABG | I | B |
| PCI | I | C |
| No anatomic or physiological criteria for revascularization | ||
| CABG | III: Harm | B |
| PCI | III: Harm | B |
| CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not available; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TIMI, Thrombolysis In Myocardial Infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; UPLM, unprotected left main disease; and VT, ventricular tachycardia. | ||
| Noninvasive Risk Stratification |
| High risk (>3% annual death or MI)
1. Severe resting LV dysfunction (LVEF <35%) not readily explained by noncoronary causes 2. Resting perfusion abnormalities ≥10% of the myocardium in patients without prior history or evidence of MI 3. Stress ECG findings including ≥2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced VT/VF 4. Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%) 5. Stress-induced perfusion abnormalities encumbering ≥10% myocardium or stress segmental scores indicating multiple vascular territories with abnormalities 6. Stress-induced LV dilation 7. Inducible wall motion abnormality (involving >2 segments or 2 coronary beds) 8. Wall motion abnormality developing at low dose of dobutamine (≤ 10 mg/kg/min) or at a low heart rate (<120 beats/min) 9. CAC score >400 Agatston units 10. Multivessel obstructive CAD (≥70% stenosis) or left main stenosis (≥50% stenosis) on CCTA |
| Intermediate risk (1% to 3% annual death or MI)
1. Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by noncoronary causes 2. Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI 3. ≥1 mm of ST-segment depression occurring with exertional symptoms 4. Stress-induced perfusion abnormalities encumbering 5% to 9.9% of the myocardium or stress segmental scores (in multiple segments) indicating 1 vascular territory with abnormalities but without LV dilation 5. Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed 6. CAC score 100 to 399 Agatston units 7. One vessel CAD with ≥70% stenosis or moderate CAD stenosis (50% to 69% stenosis) in ≥2 arteries on CCTA |
| Low risk (<1% annual death or MI)
1. Low-risk treadmill score (score ≥5) or no new ST segment changes or exercise-induced chest pain symptoms; when achieving maximal levels of exercise 2. Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of the myocardium* 3. Normal stress or no change of limited resting wall motion abnormalities during stress 4. CAC score <100 Agaston units 5. No coronary stenosis >50% on CCTA |
| CAC indicates coronary artery calcium; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; LV, left ventricular; LVEF, left ventricular ejection fraction; and MI, myocardial infarction. |
One Vessel Disease
| Appropriate Use Score (1-9) | ||||||||
|---|---|---|---|---|---|---|---|---|
| One-Vessel Disease | Asymptomatic | Ischemic Symptoms | ||||||
| One-Vessel Disease | Not on AA Therapy or With AA Therapy | Not on AA Therapy | On 1 AA Drug (BB Preferred) | On ≥2 AA Drugs | ||||
| Indication | PCI | CABG | PCI | CABG | PCI | CABG | PCI | CABG |
| No Proximal LAD or Proximal Left Dominant LCX Involvement | ||||||||
| Low-risk findings on noninvasive testing | R (2) | R (1) | R (3) | R (2) | M (4) | R (3) | A (7) | M (5) |
| Intermediate- or high-risk findings on noninvasive testing | M (4) | R (3) | M (5) | M (4) | M (6) | M (4) | A (8) | M (6) |
| No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 | M (4) | R (2) | M (5) | R (3) | M (6) | M (4) | A (8) | M (6) |
| Proximal LAD or Proximal Left Dominant LCX Involvement Present | ||||||||
| Low-risk findings on noninvasive testing | M (4) | R (3) | M (4) | M (4) | M (5) | M (5) | A (7) | A (7) |
| Intermediate- or high-risk findings on noninvasive testing | M (5) | M (5) | M (6) | M (6) | A (7) | A (7) | A (8) | A (8) |
| No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 | M (5) | M (5) | M (6) | M (6) | M (6) | M (6) | A (8) | A (7) |
| A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary artery; LCX, left circumflex artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario. | ||||||||
Two-Vessel Disease
| Appropriate Use Score (1-9) | ||||||||
|---|---|---|---|---|---|---|---|---|
| Two-Vessel Disease | Asymptomatic | Ischemic Symptoms | ||||||
| Two-Vessel Disease | Not on AA Therapy or With AA Therapy | Not on AA Therapy | On 1 AA Drug (BB Preferred) | On ≥2 AA Drugs | ||||
| Indication | PCI | CABG | PCI | CABG | PCI | CABG | PCI | CABG |
| No Proximal LAD Involvement | ||||||||
| Low-risk findings on noninvasive testing | R (3) | R (2) | M (4) | R (3) | M (5) | M (4) | A (7) | M (6) |
| Intermediate- or high-risk findings on noninvasive testing | M (5) | M (4) | M (6) | M (5) | M (6) | M (4) | A (7) | M (6) |
| No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels | M (5) | M (4) | M (6) | M (4) | A (7) | M (5) | A (8) | A (8) |
| Proximal LAD Involvement and No Diabetes Present | ||||||||
| Low-risk findings on noninvasive testing | M (4) | M (4) | M (5) | M (5) | M (6) | M (6) | A (7) | A (7) |
| Intermediate- or high-risk findings on noninvasive testing | M (6) | M (6) | A (7) | A (7) | A (7) | A (7) | A (8) | A (8) |
| No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels | M (6) | M (6) | M (6) | M (6) | A (7) | A (7) | A (8) | A (8) |
| Proximal LAD Involvement With Diabetes Present | ||||||||
| Low-risk findings on noninvasive testing | M (4) | M (5) | M (4) | M (6) | M (6) | A (7) | A (7) | A (8) |
| Intermediate- or high-risk findings on noninvasive testing | M (5) | A (7) | M (6) | A (7) | A (7) | A (8) | A (8) | A (9) |
| No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels | M (5) | M (6) | M (6) | A (7) | A (7) | A (8) | A (7) | A (8) |
| A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario. | ||||||||
Three-Vessel Disease
| Appropriate Use Score (1-9) | ||||||||
|---|---|---|---|---|---|---|---|---|
| Three-Vessel Disease | Asymptomatic | Ischemic Symptoms | ||||||
| Three-Vessel Disease | Not on AA Therapy or With AA Therapy | Not on AA Therapy | On 1 AA Drug (BB Preferred) | On ≥2 AA Drugs | ||||
| Indication | PCI | CABG | PCI | CABG | PCI | CABG | PCI | CABG |
| Low Disease Complexity (e.g., Focal Stenoses, SYNTAX ≤22) | ||||||||
| Low-risk findings on noninvasive testing | M (4) | M (5) | M (5) | M (6) | M (6) | M (6) | A (7) | A (7) |
| Intermediate- or high-risk findings on noninvasive testing - No diabetes | M (6) | A (7) | A (7) | A (7) | A (7) | A (8) | A (8) | A (8) |
| Low-risk findings on non-invasive testing - Diabetes present | M (4) | M (6) | M (5) | M (6) | A (6) | A (7) | A (7) | A (8) |
| Intermediate- or high-risk findings on noninvasive testing - Diabetes present | M (6) | A (7) | M (6) | A (8) | A (7) | A (8) | A (7) | A (9) |
| Intermediate or High Disease Complexity (e.g. Multiple Features of Complexity as Noted Previously, SYNTAX >22) | ||||||||
| Low-risk findings on noninvasive testing - No diabetes | M (4) | M (6) | M (4) | A (7) | M (5) | A (7) | M (6) | A (8) |
| Intermediate- or high-risk findings on noninvasive testing - No diabetes | M (5) | A (7) | M (6) | A (7) | M (6) | A (8) | M (6) | A (9) |
| Low-risk findings on noninvasive testing - Diabetes present | M (4) | A (7) | M (4) | A (7) | M (5) | A (8) | M (6) | A (9) |
| Intermediate- or high-risk findings on noninvasive testing - Diabetes present | M (4) | A (8) | M (5) | A (8) | M (5) | A (8) | M (6) | A (9) |
| A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; M, may be appropriate; PCI, percutaneous coronary intervention; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario. | ||||||||
Left Main Coronary Artery Stenosis
| Appropriate Use Score (1-9) | ||||||||
|---|---|---|---|---|---|---|---|---|
| Left Main Disease | Asymptomatic | Ischemic Symptoms | ||||||
| Left Main Disease | Not on AA Therapy or With AA Therapy | Not on AA Therapy | On 1 AA Drug (BB Preferred) | On ≥2 AA Drugs | ||||
| Indication | PCI | CABG | PCI | CABG | PCI | CABG | PCI | CABG |
| Isolated LMCA disease - Ostial or midshaft stenosis | M (6) | A (8) | A (7) | A (8) | A (7) | A (9) | A (7) | A (9) |
| Isolated LMCA disease - Bifurcation involvement | M (5) | A (8) | M (5) | A (8) | M (5) | A (9) | M (6) | A (9) |
| LMCA disease - Ostial or mid shaft stenosis - Concurrent multi vessel disease - Low disease burden (e.g., 1–2 additional focal stenoses, SYNTAX score ≤22) | M (6) | A (8) | M (6) | A (9) | A (7) | A (9) | A (7) | A (9) |
| Ostial or mid shaft stenosis - Concurrent multi vessel disease - Intermediate or high disease burden (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) | M (4) | A (9) | M (4) | A (9) | M (4) | A (9) | M (4) | A (9) |
| Ostial or mid shaft stenosis - Concurrent multi vessel disease - Intermediate or high disease burden (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) | M (4) | A (9) | M (4) | A (9) | M (4) | A (9) | M (4) | A (9) |
| LMCA disease - Bifurcation involvement - Low disease burden in other vessels (e.g., 1–2 additional focal stenosis, SYNTAX score ≤22) | M (4) | A (8) | M (5) | A (8) | M (5) | A (9) | M (6) | A (9) |
| LMCA disease - Bifurcation involvement - Intermediate or high disease burden in other vessels (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) | R (3) | A (8) | R (3) | A (9) | R (3) | A (9) | R (3) | A (9) |
| A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; LMCA, left main coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; R, rarely appropriate; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario. | ||||||||
IMA to LAD Patent and Without Significant Stenoses
| Appropriate Use Score (1-9) | ||||||||
|---|---|---|---|---|---|---|---|---|
| IMA to LAD Patent and Without Significant Stenoses | Asymptomatic | Ischemic Symptoms | ||||||
| Not on AA Therapy or With AA Therapy | Not on AA Therapy | On 1 AA Drug (BB Preferred) | On ≥2 AA Drugs | |||||
| Indication | PCI | CABG | PCI | CABG | PCI | CABG | PCI | CABG |
| Stenosis Supplying 1 Territory Disease (Bypass Graft or Native Artery) to Territory Other Than Anterior | ||||||||
| Low-risk findings on noninvasive testing | R (3) | R (1) | R (3) | R (2) | M (6) | R (3) | A (7) | M (4) |
| Intermediate- or high-risk findings on noninvasive testing | M (5) | R (3) | M (5) | R (3) | A (7) | M (4) | A (8) | M (5) |
| No stress test performed or, if performed, the results are indeterminate - FFR of stenosis ≤0.80 | M (4) | R (3) | M (4) | R (3) | M (6) | M (4) | A (8) | M (5) |
| Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) Not Including Anterior Territory | ||||||||
| Low-risk findings on noninvasive testing | R (3) | R (2) | M (4) | R (3) | M (6) | R (3) | A (7) | M (5) |
| Intermediate- or high-risk findings on noninvasive testing | M (5) | R (3) | M (5) | M (4) | A (7) | M (5) | A (8) | M (6) |
| A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario. | ||||||||
IMA to LAD Not Patent
| Appropriate Use Score (1-9) | ||||||||
|---|---|---|---|---|---|---|---|---|
| IMA to LAD Not Patent | Asymptomatic | Ischemic Symptoms | ||||||
| Not on AA Therapy or With AA Therapy | Not on AA Therapy | On 1 AA Drug (BB Preferred) | On ≥2 AA Drugs | |||||
| Indication | PCI | CABG | PCI | CABG | PCI | CABG | PCI | CABG |
| Stenosis Supplying 1-Territory Disease (Bypass Graft or Native Artery)–Anterior (LAD) Territory | ||||||||
| Low-risk findings on noninvasive testing | M (4) | R (3) | M (5) | R (3) | M (6) | M (4) | A (7) | M (5) |
| Intermediate- or high-risk findings on noninvasive testing | M (6) | M (4) | M (6) | M (4) | A (7) | M (5) | A (8) | M (6) |
| No stress test performed or, if performed, the results are indeterminate - FFR of stenosis ≤0.80 | M (5) | M (4) | M (6) | M (4) | A (7) | M (5) | A (7) | M (6) |
| Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) LAD Plus Other Territory | ||||||||
| Low-risk findings on noninvasive testing | M (5) | M (4) | M (6) | M (4) | A (7) | M (5) | A (7) | M (6) |
| Intermediate- or high-risk findings on noninvasive testing | M (6) | M (5) | A (7) | M (6) | A (7) | A (7) | A (8) | A (8) |
| Stenoses Supplying 3 Territories (Bypass Graft or Native Arteries, Separate Vessels, Sequential Grafts, or Combination Thereof) LAD Plus 2 Other Territories | ||||||||
| Low-risk findings on noninvasive testing | M (5) | M (5) | M (6) | M (5) | M (6) | M (6) | A (7) | A (7) |
| Intermediate- or high-risk findings on noninvasive testing | A (7) | A (7) | A (7) | A (7) | A (7) | A (7) | A (8) | A (8) |
| A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario. | ||||||||