The document discusses the 2012 Appropriate Use Criteria (AUC) for Coronary Revascularization. It provides background on the development of the AUC in 2009 and 2012. Key points include that the AUC assess the appropriateness of revascularization based on the patient's symptoms, stress test results, and angiographic findings. The AUC are meant to guide clinical decision making and improve utilization patterns, not replace clinical judgment. They classify scenarios as appropriate, uncertain, or inappropriate for revascularization.

1. Abdelkader Almanfi, MD, MRCP-UK
Texas Hear t Institute
May 9th 2013
Appropriate Use Criteria for
Coronary Revascularization

2. Objective
 Help you to use the 2012 Appropriate Use
Criteria (AUC) for Coronary Revascularization to
improve the care of your patients

3. AUC: What Did You Mean?
―AUC‖ could mean
 Area Under the Curve (Receiver Operating Characteristic Curve;
pharmacokinetic curve)
 The 2009 JACC/Circulation Paper on Appropriateness Criteria for
Coronary Revascularization
 The 2012 Appropriate Use Criteria for Coronary Revascularization
Focused Update
 Bedside assessment of the appropriateness of PCI or CABG for a given
patient
 A score (or statistics about scores) from the NCDR CathPCI Registry
or other vendors

4. Appropriateness Criteria, 2009
 Developed as a supplement to ACC/AHA Guideline
documents.
 Appropriateness criteria are designed
to examine the use of diagnostic and therapeutic
procedures
to support efficient use of medical resources
during the pursuit of quality medical care
Patel, et al. JACC 2009; 53:530-553

5. Patel, et al. JACC 2009; 53:530-553
The Writing
Committee
Extensive literature
review and synthesis
of the evidence
What are the known indications
for coronary revascularization?
- Major randomized trials
- Guidelines
- Other sources
Current understanding of
technical capabilities and
potential patient benefits of
the procedures examined
Appropriateness review of ~180*
common clinical scenarios
encountered in everyday practice in
which coronary revascularization is
frequently considered
*Did not include every
conceivable
situation (>4,000
possible scenarios)
Appropriateness Criteria, 2009

6.  Appropriateness Criteria:
 Intended to assist patients and clinicians
 Not intended to diminish the difficulty or uncertainty
of clinical decision making
 Cannot act as substitutes for sound clinical judgment
and practice experience
 Allow assessment of utilization patterns for a test or
procedure, including across providers
Appropriateness Criteria, 2009
Patel, et al. JACC 2009; 53:530-553

7.  ―The ACCF and its collaborators believe that an
ongoing review of one’s practice using these
criteria will help guide a more effective, efficient,
and equitable allocation of health care resources,
and ultimately, better patient outcomes.‖
Appropriateness Criteria, 2009
Patel, et al. JACC 2009; 53:530-553

8.  Scenarios scored by a technical panel (17 members in a modified Delphi
exercise) on a scale of 1-9.
 Scores 7-9: Appropriate, revascularization likely to
improve health outcomes or survival
 Scores 4-6: Uncertain, likelihood that
revascularization would improve health outcomes or
survival was considered uncertain
 Scores 1-3: Inappropriate, revascularization
unlikely to improve health outcomes or survival
 Health outcomes: symptoms, functional status,
and/or quality of life
Patel, et al. JACC 2009; 53:530-553
Appropriateness Criteria:
2009 Methodology

9.  In other words
 Scores 7-9: Appropriate, revascularization is generally
acceptable and is a reasonable approach for the indication
 Scores 4-6: Uncertain, revascularization may be
acceptable and may be a reasonable approach for the
indication, but more research and/or patient information is
needed to classify the indication definitively
 Scores 1-3: Inappropriate, revascularization is not
generally acceptable and is not a reasonable approach for
the indication
Patel, et al. JACC 2009; 53:530-553
Appropriateness Criteria:
2009 Methodology

10. Patel, et al. JACC 2009; 53:530-553
ClinicalPresentation
Stable
angina
STEMI
SeverityofAngina
ASx,
CCS Class I
CCS Class IV
IschemiaTests/Prognostic
Factors*
None,
Low risk
High
risk
None
Max
Medical
Therapy
No sig.
CAD
LM +
3v CAD
Anatomic
Disease
* CHF, DM, Low LVEF
A
U
I
Appropriateness Criteria: Key Variables

11. Appropriate Use Criteria for Coronary Revascularization Focused
Update 2012
Endorsed by:

12. AUC 2012
 Reassessment of clinical scenarios felt to be
affected by significant changes in the medical
literature or gaps from prior criteria
 A practical standard upon which to assess and
better understand variability in the use of
cardiovascular procedures
Patel, et al. JACC 2012; 59:

13. AUC 2012: The Fine Print
 Significant coronary stenosis:
 LMCA stenosis ≥50% luminal diameter narrowing
in the worst view by visual assessment
 Epicardial non-LMCA stenosis ≥70% luminal
diameter narrowing in the worst view by visual
assessment
 “Borderline” coronary stenosis:
 Epicardial non-LMCA stenosis 50-60% luminal
diameter narrowing
Patel, et al. JACC 2012; 59:

14. Assumptions
 No other CAD present except as specified in the
clinical scenario.
 All patients are receiving standard care,
including guideline-based risk factor
modification for primary or secondary
prevention
 Operators performing PCI or CABG have
appropriate clinical training and experience and
have satisfactory outcomes as assessed by
quality assurance monitoring
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:

15. Assumptions
 PCI or CABG is performed in a manner consistent with established standards
of care.
 No unusual extenuating circumstances exist, e.g.,
 inability to comply with antiplatelet agents
 do not resuscitate status
 patient unwilling to consider revascularization
 technically not feasible to perform revascularization
 comorbidities likely to markedly increase procedural
risk substantially
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:

16.  Maximal Anti-Ischemic Medical Therapy: the
use of at least 2 classes of therapies to reduce
anginal symptoms
 Risk of Findings on Noninvasive Testing
 Low-Risk (<1% annual cardiac mortality)
 Intermediate-Risk (1-3% annual cardiac mortality)
 High-Risk (>3% annual cardiac mortality)
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:

17. High Risk Findings on Noninvasive Testing
 Severe resting left ventricular dysfunction (LVEF <35%)
 High-risk treadmill score
 Severe exercise left ventricular dysfunction (exercise LVEF <35%)
 Stress-induced large perfusion defect (particularly if anterior)
 Stress-induced multiple perfusion defects of moderate size
 Large, fixed perfusion defect with LV dilation or increased lung
uptake (thallium-201)
 Stress-induced moderate perfusion defect with LV dilation or
increased lung uptake (thallium-201)
 Echocardiographic wall motion abnormality (involving greater than
two segments) developing at low dose of dobutamine (≤10
mg/kg/min) or at a low heart rate (<120 beats/min)
 Stress echocardiographic evidence of extensive ischemia
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:

18. Intermediate Risk Findings on Noninvasive Testing
 Mild/moderate resting left ventricular dysfunction
(LVEF = 35% to 49%)
 Intermediate-risk treadmill score
 Stress-induced moderate perfusion defect without
LV dilation or increased lung intake (thallium-
201)
 Limited stress echocardiographic ischemia with a
wall motion abnormality only at higher doses of
dobutamine involving less than or equal to two
segments
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:

19. Low Risk Findings on Noninvasive Testing
 Low-risk treadmill score
 Normal or small myocardial perfusion defect at rest
or with stress*
 Normal stress echocardiographic wall motion or no
change of limited resting wall motion abnormalities
during stress*
* Although the published data are limited, patients with
these findings will probably not be at low risk in the
presence of either a high-risk treadmill score or
severe resting left ventricular dysfunction (LVEF
<35%)
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:

20. Classification of Chest Pain
 Typical Angina (Definite):
 Substernal chest pain or discomfort
 Provoked by exertion or emotional stress
 Relieved by rest and/or nitroglycerin
 Atypical Angina (Probable):
 Lacks one of the characteristics of definite or typical
angina
 Nonanginal Chest Pain:
 Meets one or none of the typical angina
characteristics
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:

21. Canadian Cardiovascular Society (CCS)
Classification of Angina Pectoris
 CCS I: Ordinary physical activity does not cause
angina, such as walking, climbing stairs. Angina
occurs with strenuous, rapid, or prolonged exertion
at work or recreation.
 CCS II: Slight limitation of ordinary activity.
Angina occurs on walking more than 2 blocks on
the level and climbing more than one flight of
ordinary stairs at a normal pace and in normal
condition.
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:

22. Canadian Cardiovascular Society (CCS)
Classification of Angina Pectoris
 CCS III: Marked limitations of ordinary
physical activity. Angina occurs on walking one
or two blocks on the level and climbing one flight
of stairs in normal conditions and at a normal
pace.
 CCS IV: Inability to carry on any physical
activity without discomfort—anginal symptoms
may be present at rest.
Patel, et al. JACC 2012; 59:
AUC 2012: The Fine Print

23. TIMI Risk Score for Patients With Suspected
Acute Coronary Syndrome
1 point per item
 Age ≥65 years
 ≥ 3 Risk Factors for CAD
 Diabetes mellitus;
 Cigarette smoking;
 Hypertension (BP 140/90 mm Hg or on antihypertensive
medication);
 Low HDL cholesterol (<40 mg/dL);
 Family history of premature CAD (CAD in
male first-degree relative, or father less than 55, or
female first-degree relative or mother less than 65)
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:

24. TIMI Risk Score for Patients With Suspected Acute
Coronary Syndrome, continued
1 point per item
 Known CAD (stenosis ≥50%)
 Aspirin Use in Past 7 days
 Severe angina (≥2 episodes within 24 hrs)
 ST segment deviation ≥0.5 mm
 Elevated Cardiac Myonecrosis Biomarkers
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:

25. TIMI Risk Score for Patients With
Suspected Acute Coronary Syndrome
 Low Risk (0-2): 4.7-8.3% risk of death or
ischemic events through 14 days
 Intermediate Risk (3-4): 13.2-19.9% risk of
death or ischemic events through 14 days
 High Risk (5-7): 26.2-40.9% risk of death or
ischemic events through 14 days
Patel, et al. JACC 2012; 59:
AUC 2012: The Fine Print

26. AUC 2012: What’s New
15 Updated Indications
Patel, et al. JACC 2012; 59:

27. AUC 2012: What’s New
15 Updated Indications
Patel, et al. JACC 2012; 59:

28.  13 scenarios for acute coronary syndromes
 36 scenarios for non-ACS without prior bypass
surgery
 12 scenarios for non-ACS with prior bypass
surgery
 8 scenarios for advanced CAD, CCS III or IV,
and/or intermediate- to high-risk findings on
non-invasive testing
AUC 2012: The Whole Thing
69 Categories of Indications
Patel, et al. JACC 2012; 59:

29. AUC 2012: At the Bedside
Patel, et al. JACC 2012; 59:

30. AUC 2012: At the Bedside
Patel, et al. JACC 2012; 59:

31. AUC 2012: At the Bedside
Patel, et al. JACC 2012; 59:

32. AUC 2012: At the Bedside
Patel, et al. JACC 2012; 59:

33. AUC 2012: At the Bedside
Patel, et al. JACC 2012; 59:

34. SCAI AUC 2012 Tool

35. SCAI AUC 2012 Tool

36. SCAI AUC 2012 Tool

37. Limitations of the AUC
 ―Maximal antianginal medical therapy is defined
as the use of at least 2 classes of therapies to
reduce anginal symptoms.‖–intolerance,
allergies, resting heart rate and blood pressure
are not taken into account.
 Inter-rater variability in coding the results of
non-invasive testing for low, intermediate and
high risk.
Patel, et al. JACC 2012; 59:

38. Challenges in Documentation
of the AUC Inputs
 Insufficient primary documentation to assess
CCS class (e.g., ―worsening exertional angina‖)
 Lack of documentation of formal evaluation of
CCS class by a cardiologist (which leads to
inter-rater variability in imputing CCS class
from the clinical documentation and thus
difficulties with audits of CCS class against
source documentation).

39. Improving Your AUC Results
 CathPCI Registry AUC algorithm is proprietary.
 Nonetheless, you can improve your AUC scores by
 Improving clinical documentation of symptom precipitants
and non-invasive test results
 Formally documenting assessment of CCS class and
severity/risk of non-invasive test results (which makes life
easier for your CathPCI data abstractors)
 Assess AUC at the bedside prior to undertaking a coronary
revascularization
 Documenting thoroughly for cases rated to be of uncertain or
inappropriate appropriateness

40. AUC 2012: In a Nutshell
 The primary objective of the appropriate use
criteria is to improve physician decision making
and patient education regarding expected benefits
from revascularization and to guide future
research.
 The AUC are intended to evaluate overall patterns
of care regarding revascularization rather
adjudicating specific cases.
 It is not anticipated that all physicians or facilities
will have 100% of their revascularization
procedures deemed appropriate.
Patel, et al. JACC 2012; 59:

41.  The use of coronary revascularization for patients
with acute coronary syndromes and combinations
of significant symptoms and/or ischemia was felt to
be appropriate (or appropriate or uncertain).
 Revascularization of asymptomatic patients or
patients with low-risk findings on noninvasive
testing and minimal medical therapy were viewed
less favorably.
AUC 2012: In a Nutshell
Patel, et al. JACC 2012; 59:

42.  There may be clinical situations in which a use
of coronary revascularization for an indication
considered to be appropriate does not always
represent reasonable practice, such that the
benefit of the procedure does not outweigh the
risks.
AUC 2012: In a Nutshell
Patel, et al. JACC 2012; 59:

43.  The rating of a revascularization indication as
inappropriate or uncertain should not preclude
a provider from performing revascularization
procedures when there are patient- and
condition-specific data to support that decision.
Indeed, this may reflect optimal clinical care, if
supported by mitigating patient characteristics.
AUC 2012: In a Nutshell
Patel, et al. JACC 2012; 59:

44.  Uncertain indications require individual
physician judgment and understanding of the
patient to better determine the usefulness of
revascularization for a particular scenario. The
ranking of uncertain (4 to 6) should not be
viewed as excluding the use of
revascularization for such patients.
AUC 2012: In a Nutshell
Patel, et al. JACC 2012; 59:

45.  When a procedure is classified as ―Uncertain‖ it
generally means one of two things
1. There was insufficient clinical information in the
scenario. For example:
What would you do if:
This were an 85 y/o patient with typical age-related limitations?
This were a 35 y/o firefighter?
Uncertainty about “Uncertain”

46.  When a procedure is classified as ―Uncertain‖ it
generally means one of two things
1. There was insufficient clinical information in the
scenario.
2. There is not a substantial literature base upon which to
make a firm recommendation
No randomized trials on:
This were an 85 y/o patient with typical age-related limitations?
This were a 35 y/o firefighter?
Uncertainty about “Uncertain”

47.  When a procedure is classified as ―Uncertain‖ it
generally means one of two things
1. There was not enough clinical information in the
scenario.
2. There is not a substantial literature base upon which to
make a firm recommendation
Is there literature that identifies the correct treatment for this?
Uncertainty about “Uncertain”

48. JAMA June 6, 2011
Appropriateness: How do we rate?

49.  NCDR Data July 1, 2009 thru Sept 30, 2010
 Appropriateness mapping done by MAHI
 500,154 PCI procedures at 1091 facilities
355,417 (71%)
Acute:
STEMI, NSTEMI,
High-risk UA
144,737 (29%)
Non-acute:
Appropriateness: How do we rate?

50. From: WSJ July 6, 2011
Uncertainty about “Uncertain”

51. Did the Media Get it Right?

52. Did the Media Get it Right?

53. Did the Media Get it Right?

54. Did the Media Get it Right?

55. Variation in Hospital Rates of Inappropriate PCIs for
Non-Acute Indications
JAMA June 6, 2011

56. What Can You Do?
 Make certain you understand ―uncertain‖
 More importantly, make sure those entering your NCDR
data are entering variables correctly
 Develop an action plan to evaluate patients graded as
inappropriate and uncertain
 NCDR facilities can get a detailed listing of patients with these
classifications.

57. Our indoor soccer team/ Houston, Texas