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Amanda Jekowsky , American College of
Cardiology, 202-375-6645, ajekowsk@acc.org
January
5, 2009
New appropriate use criteria guide
treatment of patients with heart blockage
Practical tool aids physicians, patients, payers
If you’re committed to fitness, the decision to climb
a couple of flights of stairs rather than take the elevator
is clear. But if you develop chest pain on the way up, deciding
how to treat the symptoms of clogged arteries in your heart
is much more complicated.
Whether it’s appropriate to treat chest pain with medical
therapy alone or prescribe medical therapy and also perform
revascularization—that is, by restoring good blood flow
to the heart muscle with a balloon-tipped catheter or bypass
surgery—depends on several factors that vary from patient
to patient. In some cases the decision is obvious; in others,
it’s more nuanced.
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, titled “Appropriate
Use Criteria for Coronary Revascularization,” appears
in the February 10, 2009, issue of the Journal of the
American College of Cardiology (JACC) and online at www.acc.org.
The document will also be published in the January 5, 2009,
online issues of Catheterization and Cardiovascular Interventions
(CCI) and Circulation: Journal of the American Heart Association,
and online at www.scai.org.
“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, M.D., 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,
NC. “These recommendations describe when coronary revascularization
would be expected to improve a patient’s health status.”
The new appropriate use criteria are the first to focus on
cardiac treatment, rather than on diagnostic testing. They
were jointly developed by the American College of Cardiology,
Society for Cardiovascular Angiography and Interventions,
Society of Thoracic Surgeons, American Association for Thoracic
Surgery, American Heart Association, and American Society
of Nuclear Cardiology. They have been endorsed by the American
Society of Echocardiography, Heart Failure Society of America,
and Society of Cardiovascular Computed Tomography.
Appropriate use criteria differ from clinical guidelines both
in their purpose and their format. While guidelines provide
a comprehensive summary of evidence from clinical trials,
appropriate use criteria focus on the types of patients cardiologists
see in the clinic and hospital every day. Clinical studies
may not have included such patients and, therefore, scientific
evidence may not be readily available. Appropriate use criteria
also present information in easily understood 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.
“This was quite a serious undertaking,” said Peter
K. Smith, M.D., a cardiac surgeon member of the writing committee
on behalf of The Society of Thoracic Surgeons. “The
process involved extensive review and debate of the available
body of evidence, and resulted in remarkable consensus between
specialties.” Dr. Smith is also professor and chief
of cardiothoracic surgery at Duke University.
Revascularization was considered appropriate if the expected
improvements in survival, symptoms, functional status and/or
quality of life outweighed the possible risks. In most cases,
the panel considered revascularization as either bypass surgery
or a catheter procedure (also known as percutaneous coronary
intervention, or PCI). Because evidence is available to support
either procedure for patients with advanced coronary disease,
each method of revascularization was independently rated.
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, they deemed revascularization
appropriate if a similar patient had severe symptoms despite
already taking the best available heart medication.
Appropriate use criteria are not intended to diminish the
importance of clinical judgment in evaluating individual patients,
nor to include every possible type of patient. Instead, one
of their most important uses will be in evaluating patterns
of care, and in helping to reduce the large variation in rates
of revascularization that has been observed throughout the
country.
“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, M.D., a writing committee member and
past president of the Society for Cardiovascular Angiography
and Interventions. “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.”
Dr. Dehmer is also a professor of medicine at Texas A &
M University College of Medicine and cardiology director at
Scott & White Clinic, both in Temple, TX.
It is also hoped that health insurers 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,” Dr. 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.”
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The American College of Cardiology is leading the way to optimal
cardiovascular care and disease prevention. The College is
a 36,000-member nonprofit medical society and bestows the
credential Fellow of the American College of Cardiology upon
physicians who meet its stringent qualifications. The College
is a leader in the formulation of health policy, standards
and guidelines, and is a staunch supporter of cardiovascular
research. The ACC provides professional education and operates
national registries for the measurement and improvement of
quality care. More information about the association is available
online at www.acc.org .
The American College of Cardiology (ACC) provides these news
reports of clinical studies published in the Journal of
the American College of Cardiology as a service to physicians,
the media, the public and other interested parties. However,
statements or opinions expressed in these reports reflect
the view of the author(s) and do not represent official policy
of the ACC unless stated so.
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