ACC Revises Coronary Revascularization Criteria in Stable Ischemic Heart Disease

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The 2017 criteria utilize new terminology, classify symptoms as asymptomatic or ischemic, and expand the role of fractional flow reserve.
The 2017 criteria utilize new terminology, classify symptoms as asymptomatic or ischemic, and expand the role of fractional flow reserve.

The American College of Cardiology issued revised criteria for coronary revascularization in stable ischemic heart disease. The revised criteria were published in the Journal of the American College of Cardiology.

Although the 2017 Appropriate Use Criteria (AUC) represent a revision of the 2012 Coronary Revascularization AUC, the 2017 AUC focus on patients with stable ischemic heart disease, while the 2012 AUC applied to patients with acute coronary syndrome. In addition, the 2017 AUC take into account new guidelines for stable ischemic heart disease and new data on coronary revascularization that have been published since 2012.

“The original intent of the AUC was to provide a tool to identify patterns of care, including both the overuse and underuse of various services,” the writing group, led by Manesh R. Patel, MD, from Duke University Health System in Durham, North Carolina, wrote.

The 2017 AUC include major changes from the 2012 AUC. The 2017 criteria utilize new terminology regarding levels of appropriate care, classify symptoms as asymptomatic or ischemic (in place of the Canadian Cardiac Society classification), and expand the role of fractional flow reserve (FFR).

The revised criteria also rated the appropriateness of interventions in tables organized according to practice patterns, such as treatment with no antianginal therapy, 1 antianginal drug, or at least 2 antianginal drugs.

“We have expanded the indications that are being considered to include structural heart disease, renal transplantation,” Dr Patel told Cardiology Advisor in an interview. Patients who may benefit from the use of invasive physiology were also included.

The appropriate use ratings in the revised criteria are consistent with concepts in current clinical practice guidelines. Coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery is generally not considered appropriate as the first step for treating low-risk patients with single-vessel disease. 

Revascularization tends to be rated as “may be appropriate care” or “appropriate care” in patients with a higher burden of coronary artery disease, such as 2-vessel or 3-vessel disease. In particular, CABG surgery is often considered “appropriate care” in patients with high disease complexity.

The 2017 AUC also account for scenarios that may be applied to patients in specific situations, allowing for the criteria to be used as part of individualized care.

“[The AUC document] is intended to provide a practical guide to clinicians and patients when considering revascularization,” the writing group commented. “As with all AUC, some of these ratings will require research and further evaluation to provide the greatest information and benefit to clinical decision making.”

“We need to continue to work to incorporate and better characterize patients' symptoms into these documents,” Dr Patel added.

Reference

Coronary Revascularization Writing Group; 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 [published online March 9, 2017] J Am Coll Cardiol.  doi:10.1016/j.jacc.s2017.02.001

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