February 15th, 2012

Part 1: Clashing Views of Appropriate Use Criteria for PCI

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In a recent Viewpoint in JACC: Cardiovascular Interventions, Marso and colleagues expressed grave reservations about the application of appropriate use criteria for PCI in a controversial study published last year in JAMA by Chan and colleagues, which found that only half of PCIs performed for nonacute indications were classified as appropriate. Interventional cardiology editors Rick Lange and David Hillis asked CardioExchange members for their opinions on this topic. In this post, Lange and Hillis initiate a series of questions to the main protagonists in the debate, Steven Marso and Aaron Grantham, on the one side, and Paul Chan and John Spertus on the other side. All the authors are affiliated with the Saint Luke’s Mid America Heart Institute in Kansas City, Missouri.

Lange & Hillis: Concerns regarding the appropriateness use criteria (AUC) for coronary revascularization (published in 2009) recently have been raised. Just last month, the 2012 update to the AUC for coronary revascularization was released. Does the update adequately address these concerns? Should the AUC be updated more often?

Chan & Spertus: The AUC represent an important, proactive approach of the profession to provide a foundation for assessing the decision-making process in choosing revascularization therapy for CAD. The original version was the first attempt to quantify the quality of decision-making and will need to be updated over time for 2 reasons: a) there are methodological limitations in accurately mapping clinical scenarios; and b) there are new data to inform judgments about the appropriateness of selecting revascularization. The 2012 updates addressed some of these issues. For instance, the 2012 AUC further refine the classification of ACS (unstable angina and NSTEMI) patients into high and low risk, incorporate new clinical trial data, such as SYNTAX, into the AUC, and provide ratings for some new indications.

Marso & Grantham: We were pleased to see the coronary revascularization AUC were updated, and recently published online. The update incorporated a handful of new indications in response to recently completed clinical studies and provide an initial approach to incorporate FFR into the appropriate use criteria. These updates also re-emphasize that an “uncertain” category as not being inappropriate. These refreshed criteria serve as a reassuring signal that the committee members are receptive to evolving these criteria over time based upon new clinical trial data. These criteria really should be malleable over time, making the coronary revascularization AUC a living document.

However, these criteria were neither intended to be nor are responsive to the systematic limitations articulated in our recent Viewpoint article. There are a number action items we proposed which were not addressed that might improve the AUC including the following broad topics:

  1. Reliably determining and then documenting risk based upon noninvasive imaging studies.
  2. Developing a strategy to seek active participation by a larger number of interventional cardiologists than are currently on the AUC Technical Panel.
  3. Reconsidering indication 12B, as there remains broad disagreement that this is an inappropriate category for PCI.
  4. Reconsidering the lumping of Class 2 with Class 1 angina for the mappable clinical scenarios.
  5. Considering a strategy to co-localize a stress defect with the target lesion treated.
  6. Developing a more comprehensive strategy to incorporate a role for FFR into PCI decision making.

Note: Part 2 of this 5 part series will be published tomorrow.


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