New appropriate use criteria that describe when coronary revascularization would be expected to improve a patient’s health status, have been developed by the American College of Cardiology (ACC), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Thoracic Surgeons (STS), American Association for Thoracic Surgery (AATS), American Heart Association (AHA) and American and the Society of Nuclear Cardiology (ASNC).
Whether it’s appropriate to treat chest pain with medical therapy alone or prescribe medical therapy and also perform revascularization depends on several factors that vary from patient to patient. The ACC said that in some cases the decision is obvious; in others, it’s more nuanced. The new recommendations are the first to focus on cardiac treatment, rather than diagnostic testing, as a practical tool to aid physicians, patients and payors, the societies said.
Now, physicians, patients and health insurers have a practical tool for weighing each of those factors and arriving at the right treatment decision. The new document will appear in the Feb. 10 issue of the Journal of the American College of Cardiology. The document also was published in the Jan. 5 online issues of Catheterization and Cardiovascular Interventions and Circulation: Journal of the American Heart Association.
“One of the strengths of this document is that it provides a framework for thinking about clinical scenarios and having a discussion about coronary revascularization,” said Manesh R. Patel, MD, chair of the appropriate use criteria writing group and an assistant professor of medicine at Duke University and the Duke Clinical Research Institute in Durham, N.C.
While guidelines provide a summary of evidence from clinical trials, appropriate use criteria focus on the types of patients cardiologists see in the clinic and hospital each day.
The appropriate use criteria also present information in clinical scenarios that characterize patients according to four critical features:
- The severity and type of symptoms;
- How much cholesterol plaque has built up and in which arteries;
- How much of the heart muscle, according to stress testing, is being starved for blood and oxygen (a condition known as ischemia); and
- Whether the patient is already taking the right heart medications in the right dosages.
In developing the appropriate use criteria, a 17-member technical panel made up of general cardiologists, interventional cardiologists, cardiac surgeons, internal medicine specialists, health services researchers and others sifted through approximately 180 clinical scenarios, scoring each according to whether revascularization was appropriate, inappropriate or uncertain. [Can you link “criteria” to the actual guidelines or to a more detailed release explaining them more?]
The panel determined that revascularization would be inappropriate in a patient who had plaque build-up in one or two arteries, experienced symptoms only during heavy exercise, had a small amount of heart muscle at risk, and was not taking medication to help control symptoms. However, the panel deemed revascularization appropriate if a similar patient had severe symptoms despite already taking the best available heart medication.
“For physicians who look at the appropriate use criteria and conclude that 95 to 100 percent of the revascularization procedures they perform would be graded as appropriate—terrific,” said Gregory J. Dehmer, MD, a writing committee member and SCAI past president. “But for those who find that only 60 or 70 percent of their procedures are appropriate and the rest are inappropriate, this document provides a very powerful message and gives them a benchmark for improving their practice.”
The ACC said it is also hoped that payors will use the appropriate use criteria in developing consistent payment and preauthorization policies and in conducting quality reviews.
“In the arena of cardiovascular science, we have a fair amount of data on revascularization and its ability to improve how patients feel or long they live,” Patel said. “As a group that includes general cardiologists, interventionalists and surgeons, we’re saying: For these common clinical scenarios, here is when it’s appropriate—in most patients—to perform revascularization.”