Appropriate Use Criteria for Coronary Revascularization in Stable Ischemic Heart Disease

Patel MR, Calhoon JH, Dehmer GJ, et al.
ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease: 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 Society of Thoracic Surgeons. J Am Coll Cardiol 2017;Mar 10:[Epub ahead of print].

The following are key points to remember about the 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease (SIHD):

  1. The revascularization Appropriate Use Criteria (AUC) are based on the current understanding of procedure outcomes plus the potential patient benefits and risks of the revascularization strategies examined.
  2. This document uses the new terms “appropriate care,” “may be appropriate care,” and “rarely appropriate care,” which were described in the updated AUC methodology paper.
  3. The current criteria continue to emphasize the use of more objective measures of ischemia within indications to stratify patients into low-risk or intermediate-/high-risk findings, as described in the SIHD guideline. The scenarios also expand the use of intracoronary physiologic testing, mainly with fractional flow reserve (FFR).
  4. The structure of the AUC tables concerning the use of antianginal therapy has changed to reflect usual practice patterns rating patients on the basis of no antianginal therapy, use of one antianginal drug, or use of two or more antianginal drugs. It is assumed that all patients are being treated with optimal guideline-directed medical therapies to reduce risk.
  5. In an effort to capture patients not previously categorized, the current AUC also rate coronary revascularization in patients being considered for renal transplantation and percutaneous valve procedures.
  6. In general, in patients with a low burden of coronary disease (e.g., single-vessel disease), low-risk findings on noninvasive testing, and/or no antianginal therapy, revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery for care is thought to be rarely appropriate as the initial step.
  7. As disease burden progresses through two-vessel to three-vessel and left main disease, revascularization by PCI or CABG frequently becomes rated as “may be appropriate care” or “appropriate care,” with CABG surgery consistently rated as “appropriate care” for intermediate or high disease complexity (SYNTAX score ≥22) even in patients with ischemic symptoms who are not on antianginal therapy.
  8. Of note, CABG surgery was consistently rated as “appropriate care” and PCI as “rarely appropriate care” for left main bifurcation disease with intermediate or high disease burden in other vessels.
  9. Repeat CABG surgery was thought to be rarely appropriate in patients with a functional patent internal mammary artery graft to the left anterior descending artery (LAD).
  10. Revascularization by PCI was considered “appropriate care” for the majority of patients being evaluated before a percutaneous valve procedure.
  11. This document is intended to provide a practical guide to clinicians and patients when considering revascularization. As with all appropriateness criteria, some of these ratings will require additional research and further ongoing evaluation to provide the greatest information and benefit to clinical decision making.

Keywords: Angina Pectoris, Angina, Stable, Angiography, Cardiomyopathies, Cardiac Catheterization, Cardiac Imaging Techniques, Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Decision Making, Diabetes Mellitus, Fractional Flow Reserve, Myocardial, Guideline, Heart Arrest, Multidetector Computed Tomography, Myocardial Ischemia, Myocardial Revascularization, Patient-Centered Care, Percutaneous Coronary Intervention, Peripheral Vascular Diseases, Risk Assessment, Therapeutics, Vascular Surgical Procedures

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