Author + information
- Dean J. Kereiakes, MD⁎ ( and )
- Gregg W. Stone, MD
- ↵⁎The Christ Hospital Heart and Vascular Center, The Lindner Research Center, 2123 Auburn Avenue, Suite 424, Cincinnati, Ohio 45219
Although the appropriate use criteria (AUC) for the performance of revascularization are well meaning, important limitations include the facts that they: 1) represent the consensus of a limited group of stakeholders; 2) classify a minority of possible permutations of patient scenarios; 3) do not incorporate essential data points, including specific lesion characteristics, extent of myocardium supplied, fractional flow reserve and intravascular ultrasound data, and important comorbidities (diabetes mellitus, chronic kidney disease, and so forth); 4) are based on data recording in the National Cardiovascular Data Registry by persons with widely variable training and motivation without systematic monitoring, adjudication, or audit; 5) undervalue quality of life issues, and in this regard, ignore patient preferences; and 6) do not emphasize underuse of percutaneous coronary intervention (1–4).
In this regard, Ko et al. (5) report that almost one-third of subjects undergoing angiography in Ontario, Canada, between April 2006 and March 2007 deemed “appropriate” by U.S. AUC criteria were not revascularized. Such patients experienced appreciably worse clinical outcomes (increased incidence of death or acute coronary syndrome presentation) through 3-year follow-up (hazard ratio [HR] of revascularization vs. medical therapy: 0.61; 95% confidence interval [CI]: 0.42 to 0.88). In the accompanying editorial, Patel (6) states: “This reduction in clinical events was not seen in patients with a revascularization classification (appropriateness score) of uncertain (HR: 0.57; 95% CI: 0.28 to 1.16) or inappropriate (HR: 0.99; 95% CI: 0.48 to 2.02)” (6).
Although we agree with Dr. Patel regarding the apparent lack of benefit associated with revascularization (vs. medical therapy) in subjects scored as inappropriate (at least as regards death or new acute coronary syndrome, although chronic angina and quality of life data were not collected), we disagree with the conclusion for the “uncertain” patients. Given the point estimate and confidence interval, this may well represent type II error. As evident from the nearly identical HRs, the magnitude of benefit provided by revascularization (vs. medical therapy) may be at least as great among the “uncertain” and “appropriate” classified cohorts, but was obscured by the relative lack of power (only 326 subjects classified as uncertain vs. 991 subjects classified as appropriate). Upsizing the uncertain cohort to 991 subjects, with proportionally similar event rates for revascularized (8%; 43 events) and medically treated (15.3%; 70 events) subjects, results in an odds ratio for revascularization (vs. medical therapy) of 0.48 (95% CI: 0.31 to 0.73), a highly statistically significant difference. Thus, on the basis of this report, larger studies are warranted to determine whether the spectrum of patients benefitting from revascularization should expand to include the uncertain group (which would further enlarge the specter of underuse).
- American College of Cardiology Foundation
- Chan P.S.,
- Brindis R.G.,
- Cohen D.J.,
- et al.
- Ko D.T.,
- Guo H.,
- Wijeysundera H.C.,
- et al.,
- Cardiac Care Network (CCN) of Ontario Variations in Revascularization Practice in Ontario (VRPO) Working Group
- Patel M.R.