Percutaneous coronary intervention is an appropriate procedure for patients with two-vessel coronary artery disease with proximal left anterior descending artery and for those who have three-vessel disease with a low coronary artery disease burden, but it may not be reasonable for patients with three-vessel disease and intermediate-to-high CAD burden.
That’s according to new appropriate use criteria for coronary revascularization released Jan. 30 by the American College of Cardiology Foundation and key specialty and subspecialty societies.
Dr. Manesh Patel
In the new document – the first focused update to the original Appropriate Use Criteria (AUC) for Coronary Revascularization published in 2009 – the latter scenario is graded as "uncertain," as is percutaneous coronary intervention (PCI) for patients with isolated left main stenosis and those with left main stenosis and additional CAD with low CAD burden. Further, the procedure is inappropriate for patients with left main stenosis and additional CAD with intermediate to high CAD burden, Dr. Manesh Patel of Duke University, Durham, N.C., and colleagues on the Appropriate Use Criteria Task Force reported (J. Am. Coll. Cardiol. 2012 Jan. 30 [doi: 10.1016/j.jacc.2011.12.001]). In the previous appropriate use document, PCI was deemed inappropriate for low burden left main disease and uncertain for low-burden three-vessel disease, they stated. Coronary artery bypass grafting (CABG), on the other hand, maintained its 2009 rating of appropriate for all six clinical scenarios, the authors wrote.
In addition to the changes to the PCI appropriateness ratings above, the updated ratings indicate that coronary revascularization of the presumed culprit artery is appropriate for acute coronary syndrome patients with unstable angina/non–ST-segment elevation MI (UA/NSTEMI) with intermediate risk features – defined as a thrombolysis in myocardial infarction (TIMI) score of 3-4 – for short-term risk of death or nonfatal MI, while it is uncertain for UA/NSTEMI patients with low-risk features (TIMI score of 2 or less) for short-term risk of death or non-fatal MI. Among asymptomatic patients without prior bypass surgery, revascularization is inappropriate for those with one or two-vessel CAD with no proximal left anterior descending artery involvement and no history of invasive testing.
The updated criteria are intended to fill in the gaps identified in the prior criteria and to take into account results of clinical trials that have been reported since the initial publication, including the Synergy Between PCI With TAXUS and Cardiac Surgery (SYNTAX) trial comparing the two revascularization procedures in patients with left main or triple-vessel CAD, the authors wrote.
For the 2009 criteria, the writing group identified 180 clinical scenarios reflecting common patient presentations in everyday cardiology practice which were then rated by an expert panel comprising interventional and noninterventional cardiologists, surgeons, internal medicine physicians, and health outcomes researchers using a modified Delphi exercise to assess whether an invasive revascularization procedure would be appropriate, inappropriate, or uncertain based on symptom status, extent of medical therapy, risk level, and coronary anatomy (J. Am. Coll. Cardiol. 2009;53:530-53).
For the updated document, the writing group reassessed the clinical scenarios and identified those warranting reevaluation, expansion, or consolidation, the authors explained. In this regard, they identified and reexamined four indications possibly affected by the results of the SYNTAX trial, splitting two of them to represent levels of disease burden, as noted above. They also identified a gap in the clinical scenarios related to lower-risk UA/NSTEMI patients and asymptomatic patients with one- or two-vessel CAD not involving the proximal left anterior descending artery in whom no noninvasive testing had been performed, and developed indications to address the omissions.
Basing appropriate use criteria on current understanding of the technical capabilities and potential patient benefits, the technical panel scored each indication on a scale from 1-9. A given procedure was considered appropriate for an indication if the median score was 7-9; uncertain if the median scores was 4-6; and inappropriate if the median score was 1-3.
Clinicians can use the updated criteria as decision support or educational tools when considering the need for revascularization, the authors wrote. "Moreover, these criteria can be used to facilitate discussion with patients and/or referring physicians about revascularization," they stated, noting also that "facilities and payers may choose to use these criteria either prospectively in the design of protocols or pre-authorization procedures, or retrospectively for quality reports."
Importantly, the appropriate use criteria "are intended to evaluate overall patterns of care regarding revascularization rather than adjudicating specific cases," the authors wrote. While the criteria reflect a general assessment of when revascularization may or may not be useful for specific patient populations, "physicians and other stakeholders should continue to acknowledge the pivotal role of clinical judgment in determining whether revascularization is indicated for an individual patient."