Appropriate use doc aims to guide revascularization decision making

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Multiple societies, including the American College of Cardiology Foundation, put forth appropriate use criteria (AUC) for proper revascularization techniques to help physicians in the clinical decision making process. The recommendations provide an update to 2009 data and outline the ins and outs of revascularization in acute coronary syndromes patients; however, the authors cautioned that these types of criteria should not substitute for clinical judgment.

“The increasing prevalence of coronary artery disease (CAD), continued advances in surgical and percutaneous techniques for revascularization and concomitant medical therapy for CAD, and the costs of revascularization have resulted in heightened interest regarding the appropriate use of coronary revascularization,” the document stated.

The AUC guidelines were put forth by the American College of Cardiology Foundation (ACCF), Society of Cardiovascular Angiography and Interventions (SCAI), the Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), among others. The current appropriate use criteria were created to address gaps in the previous 2009 published guidelines, in which the writing panel identified nearly 200 clinical scenarios that reflected heart problems.

“This document helps patients, physicians and payors determine when it’s reasonable to do a procedure that is intended to improve the patient’s quality of life, health status, and long-term survival,” Manesh Patel, MD, of Duke University in Durham, N.C., and lead author of the updated appropriate use criteria, said in a statement. “It can also assist patients and physicians with health-related discussions and shared decision-making, so that patients are confident they are getting the right procedures for them.”

The current guidelines focused on two specific categories:

  • Specific indications that represent gaps that were identified when mapping the 2009 AUC to the CathPCI registry; and
  • The re-evaluation of the indications to treat multivessel CAD with symptoms by PCI or CABG (revascularization method) as a result of data from the SYNTAX trial.
The panel assigned scores to clinical scenarios to help indicate whether an invasive procedure to restore a patient's blood flow would be appropriate, inappropriate or uncertain. The panelists looked at whether clinical scenarios improved patients' quality of life.

"This update provides a reassessment of clinical scenarios the writing group believed to be affected by significant changes in the medical literature or gaps from prior criteria," Patel said. "For example, publication of the SYNTAX trial called for the re-examination of clinical scenarios for multi-vessel coronary artery disease, and implementation efforts revealed a few scenarios not captured in the 2009 publication."

The AUC guidelines reaffirmed the fact that CABG is appropriate for patient scenarios with CAD that involves two vessels and includes the proximal LAD and all variations of three-vessel and left main CAD. Additionally, the guidelines depicted PCI to be appropriate in patients who have CAD in all three arteries only if the severity of disease is low. But, the panel deemed PCI as uncertain in patients who have blockages in the left main coronary artery alone, or with blockages in other arteries and a low CAD burden. PCI was considered inappropriate by the panel in patients with left coronary artery blockages who have intermediate to high disease burden.

However, Patel offered that a procedure deemed uncertain “does not mean it’s not reasonable or should not be done.” In fact, he said that these are simply areas where not enough definitive evidence is present. “Remember, the majority of medicine may be considered uncertain by this evidence standard for improvement in health status or longevity. That’s where physicians apply their clinical experience and knowledge to patient care and patients express their wishes,” Patel summed.

“The new ratings that have changed PCI from inappropriate to uncertain for low burden left main disease, and from uncertain to appropriate for low burden three-vessel disease should result in careful selection of high-risk surgery patients for PCI,” Peter K. Smith, MD, professor and chief of cardiothoracic surgery at Duke University and co-author of the new criteria, said in a statement. "Surgeons and cardiologists will now work together to maximize the benefit and minimize the risk for these patients who are at high risk for premature mortality.”

The writing committee cautioned that AUC guidelines such as these are not meant to substitute for clinical judgment or experience and said that some patients may not be represented by the AUC due to their clinical features.