Appropriate Use Criteria for Coronary Revascularization

Study Questions:

What are the trends in percutaneous coronary intervention (PCI) utilization, patient selection, and procedural appropriateness following the introduction of appropriate use criteria?


This was a multicenter, longitudinal, cross-sectional analysis of patients undergoing PCI between July 1, 2009, and December 31, 2014, at hospitals continuously participating in the National Cardiovascular Data Registry CathPCI registry over the study period. The main outcomes measure was the proportion of nonacute PCIs classified as inappropriate at the patient and hospital level using the 2012 Appropriate Use Criteria for Coronary Revascularization. Statistical testing of trends was performed using the Cochran-Armitage test for binary variables and the Jonckheere-Terpstra test for categorical variables.


A total of 2.7 million PCI procedures from 766 hospitals were included. Annual PCI volume of acute indications was consistent over the study period (377,540 in 2010; 374,543 in 2014), but the volume of nonacute PCIs decreased from 89,704 in 2010 to 59,375 in 2014. Among patients undergoing nonacute PCI, there were significant increases in angina severity (Canadian Cardiovascular Society grade III/IV angina, 15.8% in 2010, and 38.4% in 2014), use of antianginal medications prior to PCI (at least two antianginal medications, 22.3% in 2010 and 35.1% in 2014), and high-risk findings on noninvasive testing (22.2% in 2010 and 33.2% in 2014) (p < 0.001 for all), but only modest increases in multivessel coronary artery disease (43.7% in 2010 and 47.5% in 2014, p < 0.001). The proportion of nonacute PCIs classified as inappropriate decreased from 26.2% (95% CI, 25.8%-26.6%) to 13.3% (95% CI, 13.1%-13.6%), and the absolute number of inappropriate PCIs decreased from 21,781 to 7,921. Hospital-level variation in the proportion of PCIs classified as inappropriate persisted over the study period (median, 12.6% [interquartile range, 5.9%-22.9%] in 2014).


The authors concluded that since the publication of the Appropriate Use Criteria for Coronary Revascularization in 2009, there have been significant reductions in the volume of inappropriate nonacute PCIs.


This study found significant reductions in the proportion of nonacute PCIs classified as inappropriate, from 2009 to 2014. However, there was persistent hospital-level variation in the rate of inappropriate PCIs in 2014. Collectively, these findings appear to suggest that the practice of interventional cardiology has evolved since the introduction of Appropriate Use Criteria in 2009. An important limitation is that this analysis could not determine whether the observed changes reflect real improved patient selection or overestimation/up-coding of patient symptoms. The integration of more objective assessments of patient-reported health status into routine clinical care is indicated to reduce the chances of misclassifying symptom burden.

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