2016 Appropriate Use Criteria for Coronary Revascularization in ACS

Authors:
Patel MR, Calhoon JH, Dehmer GJ, et al.
Citation:
ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2016;Dec 21:[Epub ahead of print].

The following are key points to remember about this document on Appropriate Use Criteria (AUC) for Coronary Revascularization in Patients With Acute Coronary Syndromes (ACS):

  1. The AUC for ACS are consistent with the large body of evidence and guideline recommendations that support invasive strategies to define anatomy and revascularize patients with ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) ACS.
  2. Although these AUC ratings do not compare the merits of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for revascularization in ACS, in clinical practice, patients presenting with STEMI typically are treated by PCI of the culprit stenosis.
  3. The option of surgical revascularization should be considered for patients with ACS, but less acute presentation, especially in those with complex multivessel coronary artery disease.
  4. The current AUC rate revascularization as “appropriate care” for patients presenting within 12 hours of the onset of STEMI, or up to 24 hours if there is clinical instability.
  5. For STEMI patients presenting more than 12 and up to 24 hours from symptom onset, but with no signs of clinical instability, revascularization was rated as “may be appropriate.”
  6. Nonculprit artery revascularization at the time of primary PCI was rated as “may be appropriate,” but because this is an emerging concept on the basis of relatively small studies, clinical judgment by the operator is encouraged.
  7. For STEMI patients initially treated with fibrinolysis, revascularization was rated as “appropriate therapy” in the setting of suspected failed fibrinolytic therapy or in stable and asymptomatic patients from 3 to 24 hours after fibrinolysis.
  8. The only “rarely appropriate” rating in patients with ACS occurred for asymptomatic patients with intermediate-severity nonculprit artery stenoses in the absence of any additional testing to demonstrate the functional significance of the stenosis.
  9. For patients with NSTEMI/unstable angina, and consistent with existing guidelines and the available evidence, revascularization was rated as “appropriate care” in the setting of cardiogenic shock or in a patient with intermediate- or high-risk features.
  10. For stable NSTE-ACS patients with low-risk features, revascularization was rated as “may be appropriate.”

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