This post is written by Manesh Patel, MD, FACC, lead author of the updated appropriate use criteria for coronary revascularization and the John Bush Simpson Assistant Professor of Cardiology at Duke University, assistant director of the Duke Cardiac Catheterization Laboratory and director of Duke Catheterization Lab Research.
Yesterday the ACC along with the Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, and Society of Cardiovascular Computed Tomography released updated appropriate use criteria (AUC) for coronary revascularization.
Coronary Artery Disease (CAD) occurs when the arteries supplying the heart with oxygen and nutrients narrow and become blocked. According to the National Heart, Lung, and Blood Institute, CAD is the most common type of heart disease, and is the #1 cause of death for both men and women in the U.S.
As a result of the increasing prevalence of CAD, continued advances in surgical and percutaneous techniques for revascularization and concomitant medical therapy for CAD, and the cost of revascularization, there has been heightened interest regarding the appropriate use of coronary revascularization.
The updated appropriate use criteria replace a previous set published in 2009, and help patients, physicians, and payers determine when it’s reasonable to do a procedure that is intended to improve the patient’s quality of life, health status, and long-term survival. The updated criteria can also assist patients and physicians with health-related discussions and shared decision-making, so that patients are confident they are getting the right procedures for them.
In particular, the updated criteria address the following two areas:
Re-evaluation of the indications for the treatment of multivessel CAD with symptoms by PCI and CABG as a result of data from the SYNTAX trial
, which came out after the original AUC were published; and
Specific indications that represent gaps identified when mapping the 2009 AUC to the CathPCI Registry®.
Like previous appropriate use criteria, the scope of indications is purposely broad and intended to represent the most common patient scenarios for which, in this case, coronary revascularization is considered. As a result, the clinical scenarios presented and scored were developed to represent common situations encountered in everyday practice and include information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing and coronary anatomy. They are not inclusive of every possible clinical situation.
The new appropriate use criteria will certainly stimulate discussion regarding appropriate use of revascularization. A rating of uncertain does not mean that it’s not reasonable or should not be done. These are areas where we don’t have definitive evidence and think more research is needed. That’s where physicians apply their clinical experience and knowledge to patient care and patients express their wishes. The authors and I hope physicians, surgeons, caregivers and patients have a conversation in each individual case about the best way to improve patient outcomes.
To learn more, visit CardioSource.org. Be sure to check out the Jan/Feb issue of Cardiology magazine for the complete cover story. Also view the Heart Minute video with commentary from Peter Block, MD, FACC below. Do you agree? Leave your thoughts in the comments section.