By: Gregory J. Dehmer, MD, MSCAI

SCAI has again collaborated with the American College of Cardiology, the American Heart Association, the Society of Thoracic Surgery and other organizations to develop appropriate use criteria (AUC) for coronary artery revascularization. In the last Tip-of-the-Month, we focused on the new AUC in patients with acute coronary syndromes¹. In this Tip-of-the-Month, we will focus on the new AUC for patients with stable ischemic heart disease (SIHD) highlighting the major changes compared with the prior AUC document². Both of the new AUC documents use the updated terminology for classifying appropriateness: Appropriate, May Be Appropriate and Rarely Appropriate as defined in the latest AUC methodology document³. Use of the prior terms, especially the classification designated “inappropriate” led to many concerns among operators and misunderstandings among administrators and especially in the lay press.

In addition to revised and new scenarios, the AUC for SIHD has several major changes. These changes were made in response to the many constructive comments received about the earlier versions⁴. The main changes include:

1. Change in the composition of the rating panel: The writing committee develops the organization of the AUC and the individual scenarios, but it is the votes of the rating panel members that actually determine the classification of the individual scenarios. For the new AUC, the rating panel composition was balanced with 5 interventional cardiologists (all SCAI fellows), 5 cardiac surgeons and 5 cardiologists not directly involved with the performance of revascularization procedures. In comparison, the rating panels used in the prior documents had 4 interventional cardiologists, 4 cardiac surgeons, 8 cardiologists not directly involved with the performance of revascularization procedures and one health plan official.
2. Elimination of the Canadian Cardiovascular Society (CCS) classification: The prior AUC stratified patients based on the severity of symptoms using the CCS classification scheme. Patients do not always articulate symptoms or their severity in a similar fashion and there is discordance in how physicians report patient symptoms^5,6. Because of this, the new AUC adopt a simplified approach classifying patients as either asymptomatic or having ischemic symptoms acknowledging that in some patients symptoms other than chest pain may indicate myocardial ischemia.
3. Redefinition of the use of medical therapy: In the prior AUC, one of the descriptors used related to medical therapy, specifically whether the patient was receiving no or minimal anti-ischemic therapy versus maximal anti-ischemic therapy. For the purposes of the clinical scenarios, maximal anti-ischemic therapy was defined as the use of at least 2 classes of drugs to reduce anginal symptoms. Many felt that this was not typical of real-world medical management strategies. Accordingly, antianginal use in the new AUC follows the recommendations established in the 2012 SIHD guideline⁷. Specifically, antianginal therapy begins with one drug (beta-blocker preferred) and then other drugs are added as needed to control symptoms. The options for revascularization were rated in the context of one drug or more than one drug use.
4. Greater use of SYNTAX scores and FFR: SYNTAX scores were used as an additional descriptor in patients with 2 or 3-vessel and left main disease as a convenient way to categorize disease complexity. FFR testing was used to characterize the functional significance of a stenosis mainly in scenarios without other evidence of ischemia or for stenoses of intermediate severity.
5. Evaluation of revascularization before other procedures: In a new table, revascularization before renal transplantation or structural heart procedures (TAVR, MitraClip, etc.) was rated. Both are special situations where coronary revascularization may be warranted before the procedure, but patients often do not have symptoms or lack the noninvasive testing needed to demonstrate myocardial ischemia. This rating table assumes the patient has SIHD; unstable patients are classified using the AUC for acute coronary syndromes.

Summary

In total, there are 448 specific scenarios rated within the new AUC for SIHD. A rating of rarely appropriate was assigned to 33 (7%) of the scenarios; 8 are specific for PCI and the remainder related to CABG. These are clustered among patients with low-risk noninvasive findings who are asymptomatic or on no antianginal therapy and have a low burden of disease (1 or 2-vessel CAD). A full description of the scenarios and assumptions is found in the published document².

This can be stored on your smartphones or reproduced in a large format and posted in your cath labs for easy reference.

References

1. Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, Smith PK. 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 2017;69:570–591.
2. Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, Smith PK. 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;69:2212–2241.
3. Hendel RC, Patel MR, Allen JM, Min JK, Shaw LJ, Wolk MJ, Douglas PS, Kramer CM, Stainback RF, Bailey SR, Doherty JU, Brindis RG. Appropriate use of cardiovascular technology: 2013 ACCF appropriate use criteria methodology update: a report of the American College of Cardiology Foundation appropriate use criteria task force. J Am Coll Cardiol 2013;61:1305-1317.
4. Marso SP, Teirstein PS, Kereiakes DJ, Moses J, Lasala J, Grantham JA. Percutaneous coronary intervention use in the United States: defining measures of appropriateness. JACC Cardiovasc Interv 2012;5:229-235.
5. Shafiq A, Arnold SV, Gosch K, Kureshi F, Breeding T, Jones PG, Beltrame J, Spertus JA. Patient and physician discordance in reporting symptoms of angina among stable coronary artery disease patients: Insights from the Angina Prevalence and Provider Evaluation of Angina Relief (APPEAR) study. Am Heart J 2016;175:94-100.
6. Arnold SV, Grodzinsky A, Gosch KL, Kosiborod M, Jones PG, Breeding T, Towheed A, Beltrame J, Alexander KP, Spertus JA. Predictors of physician under-recognition of angina in outpatients with stable coronary artery disease. Circ Cardiovasc Qual Outcomes 2016;9:554-559.
7. Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB III, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR Jr, Smith SC Jr, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:e44-e16.