Appropriate use criteria for revascularization: Difference between revisions

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{{cquote|Rarely an appropriate option for management of this patient population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication).}}
{{cquote|Rarely an appropriate option for management of this patient population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication).}}


<div class="mw-collapsible mw-collapsed">
==Appropriate Use Ratings for Revascularization in Acute Coronary Syndromes==
==Appropriate Use Ratings for Revascularization in Acute Coronary Syndromes==
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{{familytree/start |summary=PE diagnosis Algorithm.}}
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{{familytree | | | A01 |-|-|-| A02 |-|-|-|-|-|-|-|-| A03 |A01=UA/NSTEMI|A02=Cardiogenic shock|A03=STEMI}}  
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{{familytree | | | | | | | | | | | | | | | | E01 | | E02 | | E03 | | E04 |E01='''Appropriate Care'''|E02='''Rarely Appropriate Care'''|E03='''May Be Appropriate Care'''|E04='''Appropriate Care'''}}  
{{familytree | | | | | | | | | | | | | | | | E01 | | E02 | | E03 | | E04 |E01='''Appropriate Care'''|E02='''Rarely Appropriate Care'''|E03='''May Be Appropriate Care'''|E04='''Appropriate Care'''}}  
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''Adapted from Journal of the American College of Cardiology''
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==Clinical Scenarios==
==Clinical Scenarios==
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==References==
==References==
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[[CME Category::Cardiology]]


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Latest revision as of 23:48, 14 March 2016



Resident
Survival
Guide

Coronary Angiography

Home

General Principles

Overview
Historical Perspective
Contraindications
Appropriate Use Criteria for Revascularization
Complications
Technique
Film Quality

Anatomy & Projection Angles

Normal Anatomy

Coronary arteries
Dominance
Right System
Left System
Left Main
Left Anterior Descending
Circumflex
Median Ramus

Anatomic Variants

Separate Ostia
Anomalous Origins
Case Example
Fistula

Projection Angles

Standard Views
Left Coronary Artery
Right Coronary Artery

Epicardial Flow & Myocardial Perfusion

Epicardial Flow

TIMI Frame Count
TIMI Flow Grade
TIMI Grade 0 Flow
TIMI Grade 1 Flow
TIMI Grade 2 Flow
TIMI Grade 3 Flow
TIMI Grade 4 Flow
Pulsatile Flow
Deceleration

Myocardial Perfusion

TIMI Myocardial Perfusion Grade
TMP Grade 0
TMP Grade 0.5
TMP Grade 1
TMP Grade 2
TMP Grade 3

Lesion Complexity

ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis

Preprocedural Lesion Morphology

Eccentricity
Irregularity
Ulceration
Intimal Flap
Aneurysm
Sawtooth Pattern
Length
Ostial location
Angulation
Proximal tortuosity
Degenerated SVG
Calcification
Total occlusion
Coronary Artery Thrombus
TIMI Thrombus Grade
TIMI Thrombus Grade 0
TIMI Thrombus Grade 1
TIMI Thrombus Grade 2
TIMI Thrombus Grade 3
TIMI Thrombus Grade 4
TIMI Thrombus Grade 5
TIMI Thrombus Grade 6

Lesion Morphology

Quantitative Coronary Angiography
Definitions of Preprocedural Lesion Morphology
Irregular Lesion
Disease Extent
Arterial Foreshortening
Infarct Related Artery
Restenosis
Degenerated SVG
Collaterals
Aneurysm
Bifurcation
Trifurcation
Ulceration

Left ventriculography

Technique
Quantification of LV Function
Quantification of Mitral Regurgitation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Synonyms and keywords: AUC

Overview

The goal of the appropriate use criteria is to provide general guidance to both patients and clinicians regarding 'when' and 'how often' revascularization procedures should be done. This takes into consideration the available scientific evidences, the health care environment, the patient’s profile and a physician’s judgment. The committee acknowledges that these ratings are not meant to be a substitute for clinical judgment. Even if the appropriateness of a revascularization is listed as "rarely appropriate care" this does not mean that a physician should not perform a PCI. Likewise, even if revascularization procedure is rated as the "appropriate care", there may be mitigating circumstances that indicate PCI should not be undertaken. Rather than individual scenarios, the appropriate use criteria are meant to evaluate the overall patterns of care in different healthcare systems. If one system of care has, for instance, an 80% rate of appropriate use of revascularization whereas another system has a 40% appropriate use of revascularization, then perhaps this discrepancy should be evaluated further.

New Scoring System

Appropriate Care

Median Score 7 to 9

An appropriate option for management of this patient population due to benefits generally outweighing risks; effective option for individual care plans although not always necessary depending on physician judgment and patient specific preferences (i.e., procedure is generally acceptable and is generally reasonable for the indication).

May Be Appropriate Care

Median Score 4 to 6

At times an appropriate option for management of this patient population due to variable evidence or agreement regarding the benefits risks ratio, potential benefit based on practice experience in the absence of evidence, and/or variability in the population; effectiveness for individual care must be determined by a patient’s physician in consultation with the patient based on additional clinical variables and judgment along with patient preferences (i.e., procedure may be acceptable and may be reasonable for the indication).

Rarely Appropriate Care

Median Score 1 to 3

Rarely an appropriate option for management of this patient population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication).

Appropriate Use Ratings for Revascularization in Acute Coronary Syndromes

 
 
UA/NSTEMI
 
 
 
Cardiogenic shock
 
 
 
 
 
 
 
 
STEMI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low risk features
 
Intermediate/High risk features
 
Appropriate Care
 
 
 
Primary perfusion
 
 
 
 
 
 
 
 
 
 
 
Thrombolytic therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
May Be Appropriate Care
 
Appropriate Care
 
 
 
 
≤12 hours
 
 
 
≥12 hours
 
 
 
 
 
Asymptomatic
 
 
 
Evidence of HF, recurrent ischemia, or unstable ventricular arrhythmia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Appropriate Care
 
Severe HF, persistent ischemia, hemodynamic or electrical instability
 
Asymptomatic
 
Normal LVEF with 1-vessel disease
 
Depressed LVEF with 3-vessel disease
 
Appropriate Care
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Appropriate Care
 
Rarely Appropriate Care
 
May Be Appropriate Care
 
Appropriate Care

Adapted from Journal of the American College of Cardiology

Clinical Scenarios

Acute Coronary Syndromes

  • Revascularization in patients with UA/NSTEMI with low risk (TIMI score ≤ 2) was deemed as may be appropriate care, while those with an intermediate risk (TIMI score 3-4), it was deemed the appropriate care.
  • Revascularization in STEMI patients greater than 12 hours from symptom onset who have no symptoms of ischemia or clinical instability was deemed to be the rarely appropriate care. Likewise the need for immediate angiography in these patients was deemed unnecessary.
  • Revascularization of the non-culprit artery in STEMI patients who are not clinically unstable was deemed the appropriate care.

Stable Ischemic Heart Disease without Prior CABG

  • High risk findings on non invasive testing, greater symptoms, a large burden of disease in the native vessels increases the likelihood that the revascularization is the appropriate care.
  • In assymptomatic patients who have not undergone a stress test, PCI was deemed to be the rarely appropriate care in the presence of 1 or 2 vessel disease with no involvement of the LAD.
  • In patients who have not undergone a stress test, PCI was deemed to be the appropriate care in the presence of 1 or 2 vessel disease with or without involvement of the proximal LAD if class III or IV anginal symptoms were present. The amount of medical therapy was not included in their consideration of appropriateness.
  • In patients who have not undergone a stress test who have an intermediate stenoses, revascularization without further documentation of the significance of the stenosis by either FFR or IVUS was deemed to be the rarely appropriate care.
  • In patients who have not undergone a stress test who have severe symptoms and either an abnormal FFR or IVUS, revascularization is the appropriate care.

Stable Ischemic Heart Disease with Prior CABG

  • High risk findings on non invasive testing, greater symptoms, a large burden of disease in the native vessels or bypass conduits increases the likelihood that revascularization will be the appropriate care.
  • In patients receiving no or minimal anti-ischemic medications who had low risk findings on non-invasive testing, revasculaization is rarely the appropriate care. In this population, there are many scenarios where revascularization was deemed may be appropriate care, reflecting their higher complexity, higher risk, and the limited availability of published evidence regarding management outcome.

PCI and CABG Among Patients With Multivessel CAD

  • In general revascularization was deemed necessary in this population of patients
  • CABG was deemed to be the appropriate care in all the clinical scenarios
  • PCI was deemed to be the appropriate care in patients with:
    • 2-vessel disease with the involvement of the proximal LAD
    • 3-vessel disease with a low CAD burden (i.e., 3 focal stenoses, low SYNTAX score)
  • PCI may be appropriate care in patients with:
    • Isolated left main stenosis
    • Left main stenosis and additional CAD with low CAD burden (i.e., 1-2-vessel additional involvement, low SYNTAX score)
    • 3-vessel disease with a high CAD burden (i.e., 3 focal stenoses, high SYNTAX score)
    • 3-vessel disease CAD with intermediate to high CAD burden (i.e., multiple diffuse lesions, chronic total occlusion (CTO), or high SYNTAX score)
  • PCI is the rarely appropriate care in patients with:
    • Left main stenosis and additional CAD with intermediate to high CAD burden (i.e., 3-vessel involvement, presence of CTO, or high SYNTAX score)

Limitations

The AUC does not take into account the severity or morphology of lesions but relies upon symptoms, the results of exercise stress testing, the use of medications and simply the location of the lesion(s).

References

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