Cardiologists are selecting stable patients with greater care before performing coronary stenting according to new findings reported this morning at AHA 2015 by Nihar R. Desai, MD, MPH et. al, in the presentation “Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention – Findings From the NCDR-CathPCI Registry.”

The researchers used NCDR data to evaluate stable patients undergoing PCI at participating institutions from 2009 to 2014.  They rated patients according to the revised 2012 Appropriate Use Criteria as appropriate, uncertain, inappropriate, or unratable. 

Several trends were apparent:

• Total number of PCIs per year dropped from 538,076 to 456, 507. Almost all of the decrease was in stable or unratable patients.
• Among the one-fifth of patients undergoing PCI who were stable, those rated as “inappropriate” patients decreased by half between 2009 and 2014.
• Increases were observed in the percentage of stable patients receiving multiple anti-anginal drugs, having severely abnormal stress tests, and angina class III-IV.
• While not reported in the article, it is easy to calculate the percentage of all patients rated as inappropriate: 4% in 2010 and 1.8% in 2014.
• Variation exists among hospitals. “Inappropriate” rates were 6% in the lowest “inappropriate” quartile and 23% in the highest “inappropriate” quartile. Authors suggest that this demonstrates an opportunity for improvement in hospitals reporting the highest percentage of “inappropriate” procedures.

We interpret this report as proof that the AUC has changed clinical practice. Many hospitals are now rating patients for appropriateness before performing coronary intervention, and deferring stable patients who are “rarely appropriate.” More guideline-driven medical therapy is used before proceeding to PCI. Stable patients for whom PCI offers the greatest benefit are being stented.

SCAI’s AUC calculator is used by many members to select appropriate patients for PCI, and it will be updated as soon as new AUC are published. SCAI has used its online Quality Improvement Toolkit and Cath Lab Bootcamp educational sessions at national meetings to help members deal with the fine points of AUC ratings.

Interventionists have identified significant problems with the 2012 AUC for PCI. An updated version is being developed that addresses many of the problems in the 2012 AUC, including replacing “inappropriate” with “rarely appropriate.” 

In conclusion, we are pleased that only 1.8% of PCI patients were rated as “inappropriate” in 2014, and that interventionists are using more guideline-driven medical therapy (which is known to decrease mortality).  Recognizing all the problems with “inappropriate” as a rating, we are cautiously pleased that fewer patients in this category are undergoing PCI. We look forward to the new AUC that are expected to eliminate the term “inappropriate” in favor of the more accurate “rarely appropriate”, and more closely align with interventionists’ views of good clinical practice.