Blog | Tuesday, January 31, 2012

QD: News Every Day--Appropriate use criteria updated for when to revascularize

Updated appropriate use criteria guide were released Jan. 30 to guide physicians and patients when to use an invasive procedure to improve blood flow to the heart and how to choose the best procedure for each patient. Clinical scenarios affirm the role of revascularization for patients with acute coronary syndromes and significant symptoms.

Prominent among the changes are a re-evaluation of the indications for the treatment of multivessel coronary artery disease by percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) as a result of data from the SYNTAX trial, which came out after the original criteria were published.

The new criteria appear online at the Journal of the American College of Cardiology.

Among the many changes:
--PCI is changed from inappropriate to uncertain for low burden left main disease, and from uncertain to appropriate for low burden three-vessel disease. This is meant to generate careful selection of high-risk surgery patients for PCI.
--Coronary artery bypass is appropriate for patient scenarios with coronary artery disease involving two vessels to include the proximal left anterior descendent coronary artery and all variations of three-vessel and left main coronary artery disease.
--PCI is appropriate in patients with coronary artery disease in all three heart arteries only if the severity of coronary artery disease burden is low.
--It is uncertain whether PCI is appropriate in patients with three- vessel coronary artery disease and an intermediate to high disease burden.
--PCI is also deemed uncertain in patients with blockages in the left main coronary artery, alone or with blockages in other arteries and low coronary artery disease burden.
--PCI is considered inappropriate in patients with blockages in the left main coronary artery with intermediate to high disease burden

The updated appropriate use criteria, drafted in conjunction with 10 major cardiovascular and thoracic medical societies, replace a previous set published in 2009. New clinical data led to the update. For example, publication of the SYNTAX trial called for the reexamination of clinical scenarios for multi-vessel coronary artery disease.

The 2009 appropriate use criteria outlines nearly 200 clinical scenarios that reflect common heart problems seen by cardiologists. The appropriate use criteria scenarios were developed to mimic patient presentations encountered in everyday practice and to address the rational use of coronary revascularization. The ratings take into account such factors as symptoms, medication, results of stress testing, severity of disease burden, and number of coronary blockages.