Author + information
- Published online January 30, 2017.
- Manesh R. Patel, MD, FACC, FAHA, FSCAI, Chair, Coronary Revascularization Writing Group,
- John H. Calhoon, MD, Coronary Revascularization Writing Group Member,
- Gregory J. Dehmer, MD, MACC, MSCAI, FACP, FAHA, Coronary Revascularization Writing Group Member∗,
- James Aaron Grantham, MD, FACC, Coronary Revascularization Writing Group Member,
- Thomas M. Maddox, MD, MSc, FACC, FAHA, Coronary Revascularization Writing Group Member,
- David J. Maron, MD, FACC, FAHA, Coronary Revascularization Writing Group Member and
- Peter K. Smith, MD, FACC, Coronary Revascularization Writing Group Member†
Michael J. Wolk, MD, MACC, Moderator
Manesh R. Patel, MD, FACC, FAHA, FSCAI, Writing Group Liaison
Gregory J. Dehmer, MD, MACC, MSCAI, FACP, FAHA, Writing Group Liaison∗
Peter K. Smith, MD, FACC, Writing Group Liaison
James C. Blankenship, MD, MACC‡
Alfred A. Bove, MD, PhD, MACC‡
Steven M. Bradley, MD§
Larry S. Dean, MD, FACC, FSCAI∗
Peter L. Duffy, MD, FACC, FSCAI∗
T. Bruce Ferguson, Jr, MD, FACC‡
Frederick L. Grover, MD, FACC‡
Robert A. Guyton, MD, FACC‖
Mark A. Hlatky, MD, FACC‡
Harold L. Lazar, MD, FACC¶
Vera H. Rigolin, MD, FACC‡
Geoffrey A. Rose, MD, FACC, FASE#
Richard J. Shemin, MD, FACC‖
Jacqueline E. Tamis-Holland, MD, FACC‡
Carl L. Tommaso, MD, FACC, FSCAI∗
L. Samuel Wann, MD, MACC∗∗
John B. Wong, MD‡
Appropriate Use Criteria Task Force
John U. Doherty, MD, FACC, Co-Chair
Gregory J. Dehmer, MD, MACC, Co-Chair
Steven R. Bailey, MD, FACC, FSCAI, FAHA
Nicole M. Bhave, MD, FACC
Alan S. Brown, MD, FACC††
Stacie L. Daugherty, MD, FACC
Milind Y. Desai, MBBS, FACC
Claire S. Duvernoy, MD, FACC
Linda D. Gillam, MD, FACC
Robert C. Hendel, MD, FACC, FAHA††
Christopher M. Kramer, MD, FACC, FAHA‡‡
Bruce D. Lindsay, MD, FACC††
Warren J. Manning, MD, FACC
Manesh R. Patel, MD, FACC, FAHA§§
Ritu Sachdeva, MBBS, FACC
L. Samuel Wann, MD, MACC††
David E. Winchester, MD, FACC
Michael J. Wolk, MD, MACC††
Joseph M. Allen, MA
Table of Contents
1. Introduction 572
2. Methods 573
Indication Development 573
Scope of Indications 575
3. Assumptions 575
General Assumptions 575
4. Definitions 576
Cardiac Risk Factor Modification and Antianginal Medical Therapy 576
Culprit Stenosis 576
Symptoms of Myocardial Ischemia 576
Unstable Angina 576
Stress Testing and Risk of Findings on Noninvasive Testing 576
The Role of Patient Preference in the AUC 577
Specific Acute Coronary Syndromes 577
5. Abbreviations 578
6. Coronary Revascularization in Patients With ACS: AUC (By Indication) 578
Table 1.1 STEMI – Immediate Revascularization by PCI 578
Table 1.2 STEMI – Initial Treatment by Fibrinolytic Therapy 579
Table 1.3 STEMI – Revascularization of Nonculprit Artery During the Initial Hospitalization 579
Table 1.4 NSTEMI/Unstable Angina 579
7. Discussion 580
Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: Participants 583
Relationships With Industry and Other Entities 586
The American College of Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and American Association for Thoracic Surgery, along with key specialty and subspecialty societies, have completed a 2-part revision of the appropriate use criteria (AUC) for coronary revascularization. In prior coronary revascularization AUC documents, indications for revascularization in acute coronary syndromes (ACS) and stable ischemic heart disease were combined into 1 document. To address the expanding clinical indications for coronary revascularization, and in an effort to align the subject matter with the most current American College of Cardiology/American Heart Association guidelines, the new AUC for coronary artery revascularization were separated into 2 documents addressing ACS and stable ischemic heart disease individually. This document presents the AUC for ACS.
Clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, presence of clinical instability or ongoing ischemic symptoms, prior reperfusion therapy, risk level as assessed by noninvasive testing, fractional flow reserve testing, and coronary anatomy. This update provides a reassessment of clinical scenarios that the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document but employs the recent modifications in the methods for developing AUC, most notably, alterations in the nomenclature for appropriate use categorization.
A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range (4 to 6) indicate that coronary revascularization may be appropriate for the clinical scenario. Seventeen clinical scenarios were developed by a writing committee and scored by the rating panel: 10 were identified as appropriate, 6 as may be appropriate, and 1 as rarely appropriate.
As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with ST-segment elevation myocardial infarction and non–ST-segment elevation myocardial infarction were considered appropriate. Likewise, clinical scenarios with unstable angina and intermediate- or high-risk features were deemed appropriate. Additionally, the management of nonculprit artery disease and the timing of revascularization are now also rated. The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making.
The American College of Cardiology (ACC), in collaboration with the Society for Cardiovascular Angiography and Interventions, Society for Thoracic Surgeons, American Association for Thoracic Surgery, and other societies, developed and published the first version of the appropriate use criteria (AUC) for coronary revascularization in 2009, with the last update in 2012. The AUC are an effort to assist clinicians in the rational use of coronary revascularization in common clinical scenarios found in everyday practice. The new AUC for coronary revascularization was developed as separate documents for acute coronary syndromes (ACS) and stable ischemic heart disease (SIHD). This was done to address the expanding clinical indications for coronary revascularization, include new literature published since the last update, and align the subject matter with the ACC/American Heart Association guidelines An additional goal was to address several of the shortcomings of the initial document that became evident as experience with the use of the AUC accumulated in clinical practice.
The publication of AUC reflects 1 of several ongoing efforts by the ACC and its partners to assist clinicians who are caring for patients with cardiovascular diseases and in support of high-quality cardiovascular care. The ACC/American Heart Association clinical practice guidelines provide a foundation for summarizing evidence-based cardiovascular care and, when evidence is lacking, provide expert consensus opinion that is approved in review by the ACC and American Heart Association. However, in many areas, variability remains in the use of cardiovascular procedures, raising questions of over- or under-use. The AUC provide a practical standard upon which to assess and better understand variability.
We are grateful to the writing committee for the development of the overall structure of the document and clinical scenarios and to the rating panel, a professional group with a wide range of skills and insights, for their thoughtful deliberation of the merits of coronary revascularization for various clinical scenarios. We would also like to thank the parent AUC Task Force and the ACC staff, Joseph Allen, Leah White, and specifically Maria Velasquez, for their skilled support in the generation of this document.
Manesh R. Patel, MD, FACC
Chair, Coronary Revascularization Writing Group
Chair, Appropriate Use Criteria Task Force
Michael J. Wolk, MD, MACC
Moderator, Appropriate Use Criteria Task Force
In a continuing effort to provide information to patients, physicians, and policy makers, the Appropriate Use Task Force approved this revision of the 2012 coronary revascularization AUC (1). Since publication of the 2012 AUC document, new guidelines for ST-segment elevation myocardial infarction (STEMI) (2) and non–ST-segment elevation myocardial infarction (NSTEMI)/unstable angina (3) have been published with additional focused updates of the SIHD guideline and a combined focused update of the percutaneous coronary intervention (PCI) and STEMI guideline (4,5). New clinical trials have been published extending the knowledge and evidence around coronary revascularization, including trials that challenge earlier recommendations about the timing of nonculprit vessel PCI in the setting of STEMI (6–8). Additional studies related to coronary artery bypass graft surgery, medical therapy, and diagnostic technologies such as fractional flow reserve (FFR) have emerged as well as analyses from The National Cardiovascular Data Registry (NCDR) on the existing AUC that provide insights into practice patterns, clinical scenarios, and patient features not previously addressed (9–11).
In an effort to make the AUC usable, meaningful, and as up-to-date as possible, the writing group was asked to develop AUC specifically for coronary revascularization in ACS including STEMI to coincide with the recently published focused update of the STEMI guidelines (5). A new separate AUC document specific to SIHD is under preparation and will be forthcoming. The goal of the writing group was to develop clinical indications (scenarios) that reflect typical situations encountered in everyday practice, which are then classified by a separate rating panel using methodology previously described in detail (12) (Figure 1). In addition, step-by-step flow charts are provided to help use the criteria.
A multidisciplinary writing group consisting of cardiovascular health outcomes researchers, interventional cardiologists, cardiothoracic surgeons, and general cardiologists was convened to review and revise the coronary revascularization AUC.
The revascularization AUC are on the basis of our current understanding of procedure outcomes plus the potential patient benefits and risks of the revascularization strategies examined. The AUC are developed to identify many of the common clinical scenarios encountered in practice, but cannot possibly include every conceivable patient presentation. (In this document, the phrase “clinical scenario” is frequently used interchangeably with the term “indication.”) Some patients seen in clinical practice are not represented in these AUC or have additional extenuating features that would alter the appropriateness of treatment compared with the exact clinical scenarios presented.
AUC documents often contain more detailed clinical scenarios than the more generalized situations covered in clinical practice guidelines, and thus, subtle differences between these documents may exist. Furthermore, because recommendations for revascularization or the medical management of coronary artery disease (CAD) are found throughout several clinical practice guidelines, the AUC ratings herein are meant to unify related clinical practice guidelines and other data sources and provide a useful tool for clinicians. The AUC were developed with the intent to assist patients and clinicians, but are not intended to diminish the acknowledged complexity or uncertainty of clinical decision-making and should not be a substitute for sound clinical judgment. There are acknowledged evidence gaps in many areas where clinical judgment and experience must be blended with patient preferences, and the existing knowledge base must be defined in clinical practice guidelines.
It is important to emphasize that a rating of appropriate care does not mandate that a procedure or revascularization strategy be performed, may be appropriate care represents reasonable care and can be considered by the patient and provider, and finally, a rating of rarely appropriate care should not prevent a therapy from being performed. It is anticipated that there will be some clinical scenarios rated as rarely appropriate where an alternative therapy or performing revascularization may still be in the best interest of a particular patient. Situations where the clinician believes a therapy contrary to the AUC rating is best for the patient may require careful documentation as to the specific patient features not captured in the clinical scenario or the rationale for the chosen therapy. Depending on the urgency of care, obtaining a second opinion may be helpful in some of these settings.
The AUC can be used in several ways. As a clinical tool, the AUC assist clinicians in evaluating possible therapies under consideration and can help better inform patients about their therapeutic options. As an administrative and research tool, the AUC provide a means to compare utilization patterns across a large subset of providers to deliver an assessment of an individual clinician’s management strategies with those of similar physicians. It is important to again emphasize that the AUC should be used to measure overall patterns of clinical care rather than to adjudicate the appropriateness of individual cases. The ACC and its collaborators believe that an ongoing review of one’s practice using these criteria will help guide more effective, efficient, and equitable allocation of healthcare resources, and ultimately lead to better patient outcomes. Under no circumstances should the AUC be used as the sole means to adjudicate or determine payment for individual patients—rather, the intent of the AUC is to provide a framework to evaluate overall clinical practice and to improve the quality of care.
In developing these AUC for coronary revascularization, the rating panel was asked to rate each indication using the following definition of appropriate use:
A coronary revascularization or antianginal therapeutic strategy is appropriate care when the potential benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the potential negative consequences of the treatment strategy.
Although antianginal therapy is mentioned in this definition, the writing committee acknowledges that the focus of this document is revascularization, as it is the dominant therapy for patients with ACS. Medical therapy may have a role in the management of ongoing ischemic symptoms, but not to the extent that it does for SIHD.
The rating panel scored each indication on a scale from 1 to 9 as follows:
Score 7 to 9: Appropriate care
Score 4 to 6: May be appropriate care
Score 1 to 3: Rarely appropriate care
Appropriate Use Definition and Ratings
In rating these criteria, the rating panel was asked to assess whether the use of revascularization for each indication is “appropriate care,” “may be appropriate care,” or “rarely appropriate care” using the following definitions and their associated numeric ranges.
Median Score 7 to 9: Appropriate Care
An appropriate option for management of patients in this population due to benefits generally outweighing risks; an 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).
Median Score 4 to 6: May Be Appropriate Care
At times, an appropriate option for management of patients in this population due to variable evidence or agreement regarding the risk-benefit ratio, potential benefit on the basis of 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 on the basis of additional clinical variables and judgment along with patient preferences (i.e., procedure may be acceptable and may be reasonable for the indication).
Median Score 1 to 3: Rarely Appropriate Care
Rarely an appropriate option for management of patients in this 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).
Scope of Indications
The indications for coronary revascularization in ACS were developed considering the following common variables:
1. The clinical presentation (STEMI, NSTEMI, or other ACS);
2. Time from onset of symptoms;
3. Presence of other complicating factors (severe heart failure or cardiogenic shock; hemodynamic or electrical instability, presence of left ventricular dysfunction, persistent or recurring ischemic symptoms);
4. Prior treatment by fibrinolysis;
5. Predicted risk as estimated by the Thrombolysis In Myocardial Infarction score;
6. Relevant comorbidities; and
7. Extent of anatomic disease in the culprit and nonculprit arteries.
The writing group characterized ACS and their management into the 2 common clinical presentations: STEMI and NSTEMI/unstable angina. The anatomic construct for CAD is on the basis of the presence or absence of important obstructions in the coronary arteries categorized by the number of vessels involved 1-, 2-, and 3-vessel CAD) and the ability to identify the culprit artery responsible for the ACS Although the culprit stenosis is frequently obvious from the coronary angiogram, there are situations where the location of the culprit stenosis is uncertain or where multiple culprit stenoses may exist.
After initial treatment of the patient with an ACS, it may be helpful to categorize the amount of myocardium at risk or affected by ischemia; thus, a minority of scenarios include noninvasive testing. The writing group characterized noninvasive test findings as low-risk versus intermediate- or high-risk, as these terms are routinely used in clinical practice. The use of FFR measurement is increasing in the setting of stable ischemic heart disease, but there are limited data on its utility in the setting of ACS to evaluate nonculprit vessels (6). Nevertheless, the writing group provided some indications with invasive physiology testing (represented by FFR) in nonculprit vessels in patients with ACS.
Specific instructions and assumptions used by the rating panel to assist in the rating of clinical scenarios are listed in the following text:
1. Each clinical scenario is intended to provide the key information typically available when a patient presents with an ACS, recognizing that especially in the setting of an STEMI, the need for rapid treatment may prevent a complete evaluation.
2. Although the clinical scenarios should be rated on the basis of the published literature, the writing committee acknowledges that in daily practice, decisions about therapy are required in certain patient populations that are poorly represented in the literature. Therefore, rating panel members were instructed to use their best clinical judgment and experience in assigning ratings to clinical scenarios that have low levels of evidence.
3. In ACS, the percent luminal diameter narrowing of a stenosis may be difficult to assess. Determining the significance of a stenosis includes not only the percent luminal diameter narrowing, but also the angiographic appearance of the stenosis and distal flow pattern. For these clinical scenarios, a coronary stenosis in an artery is defined as:
a. A ≥70% luminal diameter narrowing of an epicardial stenosis made by visual assessment in the “worst view” angiographic projection; or
b. A ≥50% luminal diameter narrowing of the left main artery made by visual assessment, in the “worst view” angiographic projection.
c. A ≥50% and <70% diameter narrowing of an epicardial stenosis made by visual assessment in the “worst view” angiographic projection.
4. For scenarios reflecting later phases of care for patients with ACS (scenarios during hospitalization), assume that patients are receiving guideline-directed medical therapy for secondary prevention of cardiac events unless specifically noted and efforts to control other risk factors have started (13–17).
5. Operators performing percutaneous or surgical revascularization have appropriate clinical training and experience and have satisfactory outcomes as assessed by quality assurance monitoring (18–20).
6. Revascularization by either percutaneous or surgical methods is performed in a manner consistent with established standards of care at centers with quality/volume standards (18–20).
7. No unusual extenuating circumstances exist in the clinical scenarios such as but not limited to do-not-resuscitate status, advanced malignancy, unwillingness to consider revascularization, technical reasons rendering revascularization infeasible, or comorbidities likely to markedly increase procedural risk.
8. Assume that the appropriateness rating applies only to the specific treatment strategy outlined in the scenario and not additional revascularization procedures that may be performed later in the patient’s course. Specifically, additional elective revascularization procedures (so called delayed staged procedures) performed after the hospitalization for ACS are evaluated and rated in the forthcoming AUC document on SIHD. For data collection purposes, this will require documenting that the procedure is staged (either PCI or hybrid revascularization with surgery).
9. As with all previously published clinical policies, deviations by the rating panel from prior published documents were driven by new evidence and/or implementation of knowledge that justifies such evolution. However, the reader is advised to pay careful attention to the wording of an indication in the present document and should avoid making comparisons to prior documents.
10. Indication ratings contained herein supersede the ratings of similar indications contained in previous AUC coronary revascularization documents.
Definitions of terms used throughout the indication set are listed here. These definitions were provided to and discussed with the rating panel before the rating of indications. The writing group assumed that noninvasive assessments of coronary anatomy (i.e., cardiac computed tomography, cardiac magnetic resonance angiography) provide anatomic information that is potentially similar to X-ray angiography. However, these modalities do not currently provide information on ischemic burden and are not assumed to be present in the clinical scenarios.
A set of patient-specific conditions defines an “indication,” which is used interchangeably with the phrase “clinical scenario.”
Cardiac Risk Factor Modification and Antianginal Medical Therapy
The indications assume that patients are receiving guideline-directed medical therapies for their ACS including antiplatelet and anticoagulant medications, beta-blockers, statins, and other medications as indicated by their clinical condition.
The phrase “culprit stenosis” is often used interchangeably with “infarct-related artery” to identify the coronary artery stenosis and/or artery responsible for the ACS. In this document, the phrase “culprit stenosis or culprit artery” is preferred, because in the setting of unstable angina there may be a culprit stenosis or culprit artery, but by definition, there is no evidence of a myocardial infarction.
Symptoms of Myocardial Ischemia
For the purposes of the clinical scenarios in this document, the AUC are intended to apply to patients who have the typical underlying pathology of an ACS, not simply an elevated troponin value in the absence of an appropriate clinical syndrome. The symptoms of an ACS may be described as both typical and atypical angina or symptoms felt to represent myocardial ischemia, such as exertional dyspnea, and are captured under the broad term “ischemic symptoms.” Although previous AUC had used the Canadian Cardiovascular Society system for anginal classification, the writing group recognized that the broad spectrum of ischemic symptoms may limit patients’ functional status in a variety of ways, and capturing the Canadian Cardiovascular Society status in clinical practice may also vary widely. Therefore, the presence or absence of ischemic symptoms are presented without specific scale. Additionally, post–ACS symptoms may persist and/or be easily provoked with minimal activity.
The definition of unstable angina is largely on the basis of the clinical presentation. Unstable angina is defined as typical chest pain or other ischemic symptoms occurring at rest or with minimal exertion, and presumed to be related to an acutely active coronary plaque. In contrast to stable angina, unstable angina is often described as severe and as a frank pain. Moreover, unstable angina may be new in onset or occur in a crescendo pattern in a patient with a previous stable pattern of angina. Unstable angina may be associated with new electrocardiographic changes such as transient ST-segment elevation, ST-segment depression, or T-wave inversion, but may be present in the absence of electrocardiographic changes. Several scoring systems exist for determining high-risk patients with ACS (Tables A and B⇓⇓).
Stress Testing and Risk of Findings on Noninvasive Testing
Stress testing and coronary CTA are commonly used for both diagnosis and risk stratification of patients with coronary artery disease or those with suspected ACS. Although often contraindicated in ACS, stress testing may be performed for further risk stratification later during the index hospitalization. Risk stratification by noninvasive testing is defined as (4):
Low-risk stress test findings: associated with a <1% per year cardiac mortality rate.
Intermediate-risk stress test findings: associated with a 1% to 3% per year cardiac mortality rate.
High-risk stress test findings: associated with a >3% per year cardiac mortality rate.
The Role of Patient Preference in the AUC
Patients often make decisions about medical treatments without a complete understanding of their options. Patient participation or shared decision-making describes a collaborative approach where patients are provided evidence-based information on treatment choices and are encouraged to use the information in an informed dialogue with their provider to make decisions that not only use the scientific evidence, but also align with their values, preferences, and lifestyle (23–25). The alternative decision paradigm, often referred to as medical paternalism, places decision authority with physicians and gives the patient a more passive role (26).
Shared decision-making respects both the provider’s knowledge and the patient’s right to be fully informed of all care options with their associated risks and benefits. It also suggests that the healthcare team has educated the patient to the extent the patient desires with regard to the risk and benefits of different treatment options. The patient is given the opportunity to participate in the decision regarding the preferred treatment. Especially regarding primary PCI for STEMI, the need for rapid treatment will often preclude a detailed discussion of the risks and benefits of invasive therapy or other possible treatment decisions. However, patient preferences should be considered when the treatment of a nonculprit stenosis is contemplated later during the hospitalization.
Specific Acute Coronary Syndromes
The writing group developed these clinical scenarios around the common clinical situations in which coronary revascularization is typically considered on the basis of evidence and recommendations from the 2013 STEMI guideline (2) and 2014 NSTEMI/unstable angina guideline (3). Because of 3 recent studies and the 2015 update to the PCI/STEMI guidelines, treatment of nonculprit related arteries at the time of the initial procedure or during the initial hospitalization is also explored (5–8). Previously, treatment of nonculprit stenoses during the initial procedure or during the same hospitalization in the absence of clinical instability or further testing documenting ischemia was assigned a Class III recommendation in guideline documents and is thus considered inappropriate using the original terminology for the AUC. The 3 new randomized studies have challenged this concept, leading to a focused update of the PCI/STEMI guideline and the new Class IIb assignment for treatment of nonculprit stenoses in the setting of primary PCI.
However, the timing of treatment and criteria for nonculprit stenosis treatment varied among these 3 studies as shown in Table C.
In PRAMI (Preventive Angioplasty in Acute Myocardial Infarction Trial), the nonculprit stenosis needed to have a diameter stenosis >50% and be deemed treatable by the operator. There were exclusions to immediate nonculprit PCI, such as left main stenosis, ostial left anterior descending coronary artery and circumflex stenoses, and prior coronary artery bypass graft surgery. Treatment at any time other than during the primary PCI was discouraged. In CvLPRIT (Complete Versus Lesion-Only Primary PCI Trial), the nonculprit stenosis was required to have >70% diameter stenosis in 1 angiographic plane or >50% in 2 planes and in an artery >2 mm suitable for stent implantation. Treatment of the nonculprit stenosis immediately following the primary PCI was encouraged, but could be deferred to later during the same hospitalization. In DANAMI3-PRIMULTI (The Third Danish Study of Optimal Acute Treatment of Patients with STEMI: Primary PCI in Multivessel Disease), nonculprit stenoses were treated if the diameter stenosis was >50% and the FFR <0.80 or if the diameter stenosis alone was >90%. Treatment of the nonculprit stenoses was planned for 2 days after the primary PCI during the index hospitalization. These variations in the criteria for nonculprit stenosis treatment and timing of treatment from these 3 relatively small studies make it challenging to develop clinical scenarios. This is an evolving shift in the treatment paradigm for patients presenting with STEMI that, at present, is incompletely understood. Scenarios were developed to allow the rating panel to evaluate clinical situations that mirror the evidence provided in these new trials.
This AUC only covers clinical scenarios where the culprit artery and additional nonculprit arteries are treated at the time of primary PCI or later during the initial hospitalization. The writing group recognizes there may be circumstances where treatment of a nonculprit artery is deferred beyond the initial hospitalization. That specific circumstance was not studied in the 3 recent trials of nonculprit stenosis treatment. However, if the characteristics of the patient are such that treatment of nonculprit stenoses are deferred beyond the initial hospitalization, it is assumed the patient is clinically stable. These clinical scenarios will be evaluated in the forthcoming SIHD document.
ACS = acute coronary syndrome
AUC = appropriate use criteria
CAD = coronary artery disease
FFR = fractional flow reserve
NSTEMI = non–ST-segment elevation myocardial infarction
PCI = percutaneous coronary intervention
SIHD = stable ischemic heart disease
STEMI = ST-segment elevation myocardial infarction
6 Coronary Revascularization in Patients With ACS: AUC (By Indication)
Scenarios 1 to 3 in Table 1.1⇑ specifically address treatment of the culprit stenosis at the time intervals and with the presence or absence of symptoms as noted. Scenarios 4 to 6 in Table 1.1 specifically address treatment of 1 or more nonculprit stenoses during the same procedure as treatment of the culprit stenosis. Because these scenarios are specific for nonculprit treatment immediately following primary PCI, the criteria for treatment used in DANAMI3-PRIMULTI cannot be applied in this table.
As noted in Table 1.1, treatment of the nonculprit artery can occur at several different times after treatment of the culprit stenosis. Because Table 1.1 covers those scenarios where nonculprit treatment occurs immediately after the primary PCI, this table is specific for treatment of nonculprit stenoses after the initial procedure, but during the initial hospitalization⇑⇑.
Unstable angina/NSTEMI category—in patients with Thrombolysis In Myocardial Infarction 3 flow and multiple coronary artery stenoses, consideration should be given for heart team evaluation in patients with a high burden of CAD, such as 2-vessel disease with proximal left anterior descending coronary artery stenosis or more severe disease.
The new AUC ratings for ACS are consistent with existing guidelines for STEMI and NSTEMI-ACS (Figure 2). For patients with ACS, revascularization by either PCI or CABG is the most commonly used therapy, and this is reflected in the ratings of “appropriate care” or “may be appropriate care” for all but 1 of the 17 scenarios presented. Although these AUC ratings do not compare the merits of PCI versus CABG for revascularization in ACS, in clinical practice, patients presenting with STEMI typically are treated by PCI of the culprit stenosis. However, the option of surgical revascularization should be considered for patients with ACS but less acute presentation, especially in those with complex multivessel CAD.
The current AUC rate revascularization as “appropriate care” for patients presenting within 12 hours of the onset of STEMI or up to 24 hours if there is clinical instability. For STEMI patients presenting more than 12 and up to 24 hours from symptom onset but with no signs of clinical instability, revascularization was rated as “may be appropriate,” indicating that many on the technical panel consider it reasonable to revascularize such patients. Furthermore, nonculprit artery revascularization at the time of primary PCI was rated as “may be appropriate,” but because this is an emerging concept on the basis of relatively small studies, clinical judgment by the operator is encouraged.
For STEMI patients initially treated with fibrinolysis, revascularization was rated as “appropriate therapy” in the setting of suspected failed fibrinolytic therapy or in stable and asymptomatic patients from 3 to 24 hours after fibrinolysis. In the setting of suspected failed fibrinolysis, the need for revascularization is usually immediate, whereas in stable patients with apparent successful fibrinolysis, revascularization can be delayed for up to 24 hours. For stable patients >24 hours after fibrinolysis, revascularization was rated as “may be appropriate.” Revascularization soon after apparent successful fibrinolysis is supported by data and guideline recommendations about the management of patients transferred from centers where PCI is not available.
Nonculprit artery revascularization during the index hospitalization after primary PCI or fibrinolysis was also rated as appropriate and reasonable for patients with 1 or more severe stenoses and spontaneous or easily provoked ischemia or for asymptomatic patients with ischemic findings on noninvasive testing. In the presence of an intermediate-severity nonculprit artery stenosis, revascularization was rated as “appropriate therapy” provided that the FFR was ≤0.80. For patients who are stable and asymptomatic after primary PCI, revascularization was rated as “may be appropriate” for 1 or more severe stenoses even in the absence of further testing. The only “rarely appropriate” rating in patients with ACS occurred for asymptomatic patients with intermediate-severity nonculprit artery stenoses in the absence of any additional testing to demonstrate the functional significance of the stenosis.
For patients with NSTEMI/unstable angina, and consistent with existing guidelines and the available evidence, revascularization was rated as “appropriate care” in the setting of cardiogenic shock or in a patient with intermediate- or high-risk features. For stable patients with low-risk features, revascularization was rated as “may be appropriate.” Decisions around the timing of revascularization, management of multivessel disease, and concomitant pharmacotherapy should all be on the basis of evidence from the relevant practice guidelines.
In conclusion, the AUC for ACS are consistent with the large body of evidence and guideline recommendations that support invasive strategies to define anatomy and revascularize patients with STEMI and NSTEMI-ACS. The evolving evidence around nonculprit stenosis revascularization has led to ratings that revascularization may be appropriate after primary PCI in selected asymptomatic patients with severe stenoses, defined herein as ≥70% diameter narrowing, or in patients with intermediate-severity stenosis if FFR testing is abnormal. As in prior versions of the AUC, these revascularization ratings should be used to reinforce existing management strategies and identify patient populations that need more information to identify the most effective treatments.
ACC President and Staff
Richard A. Chazal, MD, FACC, President
Shalom Jacobovitz, Chief Executive Officer
William J. Oetgen, MD, FACC, Executive Vice President, Science, Education, and Quality
Joseph M. Allen, MA, Team Leader, Clinical Policy and Pathways
Leah White, MPH, CCRP, Team Leader, Appropriate Use Criteria
Marίa Velásquez, Senior Research Specialist, Appropriate Use Criteria
Amelia Scholtz, PhD, Publications Manager, Clinical Policy and Pathways
Appendix A Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: Participants
Manesh R. Patel, MD, FACC, FAHA, FSCAI—Associate Professor of Medicine, Director Interventional Cardiology and Catheterization Labs, Duke University Health System, Duke Clinical Research Institute, Durham, NC
John H. Calhoon, MD—Professor and Chair, Presidents Council Chair for Excellence in Surgery, Department of Cardiothoracic Surgery, Director, University of Texas Health Science Center at San Antonio, Heart and Vascular Institute, San Antonio, TX
Gregory J. Dehmer, MD, MACC, MSCAI, FACP, FAHA—Clinical Professor of Medicine, Texas A&M Health Science Center College of Medicine, Medical Director, Cardiovascular Services, Central Texas Division, Director, Cardiology Division, Baylor Scott & White–Temple Memorial, Temple, TX
James Aaron Grantham, MD, FACC—Associate Clinical Professor, University of Missouri–Kansas City School of Medicine, Director, Cardiovascular Disease Fellowship Program, University of Missouri–Kansas City School of Medicine, Director, Cardiovascular Medical Education, Saint Luke's Hospital, Kansas City, MO
Thomas M. Maddox, MD, MSc, FACC, FAHA—National Director, VA CART Program Cardiology, VA Eastern Colorado Health Care System, Associate Professor, Department of Medicine, Cardiology, University of Colorado, Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
David J. Maron, MD, FACC, FAHA—Clinical Professor of Medicine, Cardiovascular, Director, Preventive Cardiology, ISCHEMIA Trial Co-Chair, Principal Investigator, Stanford University School of Medicine, Stanford, CA
Peter K. Smith, MD, FACC—Professor of Surgery, Division Chief, Cardiovascular and Thoracic Surgery, Duke University, Durham, NC
Michael J. Wolk, MD, MACC, Moderator—Past President, American College of Cardiology, Clinical Professor of Medicine, Weill Medical College of Cornell University, New York Cardiology Associates, New York, NY
Manesh R. Patel, MD, FACC, FAHA, FSCAI, Writing Committee Liaison—Associate Professor of Medicine, Director Interventional Cardiology and Catheterization Labs, Duke University Health System, Duke Clinical Research Institute, Durham, NC
Gregory J. Dehmer, MD, MACC, MSCAI, FAHA, Writing Committee Liaison—Clinical Professor of Medicine, Texas A&M Health Science Center College of Medicine, Medical Director, Cardiovascular Services, Central Texas Division, Director, Cardiology Division, Baylor Scott and White, Temple Memorial, Temple, TX
Peter K. Smith, MD, FACC, Writing Committee Liaison—Professor of Surgery, Division Chief, Cardiovascular and Thoracic Surgery, Duke University, Durham, NC
James C. Blankenship, MD, MACC—Staff Physician, Director, Cardiac Catheterization Laboratory, Division of Cardiology, Geisinger Medical Center, Danville, PA
Alfred A. Bove, MD, PhD, MACC—Past President, American College of Cardiology, Professor Emeritus, Lewis Katz School of Medicine, Heart and Vascular, Temple University, Philadelphia, PA
Steven M. Bradley, MD—Staff Cardiologist, VA Eastern Colorado Health Care System, Assistant Professor of Medicine, Division of Cardiology at the University of Colorado, Denver, CO
Larry S. Dean, MD, FACC, FSCAI—Professor of Medicine and Surgery, University of Washington School of Medicine, Director, University of Washington, Medicine Regional Heart Center, Seattle, WA
Peter L. Duffy, MD, FACC, FSCAI—Director of Quality for the Cardiovascular Service Line, First Health of the Carolinas, Reid Heart Institute/Moore Regional Hospital, Pinehurst, NC
T. Bruce Ferguson, Jr., MD, FACC—Professor of Thoracic Surgery, Department of Cardiovascular Sciences, Cardiothoracic Surgery, East Carolina Heart Institute, East Carolina University, Greenville, NC
Frederick L. Grover, MD, FACC—Professor of Cardiothoracic Surgery, Department of Cardiothoracic Surgery, University of Colorado, Denver, CO
Robert A. Guyton, MD, FACC—Chief of Cardiothoracic Surgery, Professor of Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Director, Thoracic Surgery Residency Program, Emory University School of Medicine, Atlanta, GA
Mark A. Hlatky, MD, FACC—Professor of Heath Research and Policy, Health Services Research, Professor of Medicine, Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
Harold L. Lazar, MD, FACC—Director, Cardiothoracic Research Program, Professor of Cardiothoracic Surgery, Boston University School of Medicine, Boston, MA
Vera H. Rigolin, MD, FACC—Professor, Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
Geoffrey A. Rose, MD, FACC, FASE—Chief, Division of Cardiology, Sanger Heart and Vascular Institute, Charlotte, NC
Richard J. Shemin, MD, FACC—Robert and Kelly Day Professor, Chief of Cardiothoracic Surgery, Executive Vice Chair of Surgery, Co-Director of the Cardiovascular Center, Director of Cardiac Quality at the Ronald Reagan UCLA Medical Center, Los Angeles, CA
Jacqueline E. Tamis-Holland, MD, FACC—Director, Interventional Cardiology Fellowship, Mount Sinai, Saint Luke's Hospital Director, Women's Heart NY Assistant Professor of Medicine, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
Carl L. Tommaso, MD, FACC, FSCAI—Director of the Cardiac Catheterization Laboratory at Skokie Illinois Hospital, part of the Northshore University Health System, Associate Professor of Medicine at Rush Medical College in Chicago, Chicago, IL
L. Samuel Wann, MD, MACC—Past President, American College of Cardiology, Clinical Cardiologist, Columbia St. Mary’s Healthcare, Medical Director, Heart Failure Program, Milwaukee, WI
John B. Wong, MD—Chief, Division of Clinical Decision Making, Primary Care Physician, Principal Investigator, Institute for Clinical Research and Health Policy Studies, Professor, Tufts University School of Medicine, Boston, MA
Jeffrey L. Anderson, MD, FACC—Associate Chief of Cardiology, Intermountain Medical Center, Murray, UT
James C. Blankenship, MD, MACC—Staff Physician, Director, Cardiac Catheterization Laboratory, Geisinger Medical Center, Division of Cardiology, Danville, PA
Jeffrey A. Brinker, MD, FACC—Professor of Medicine, Johns Hopkins Hospital, Baltimore, MD
Alexandru I. Costea, MD—Associate Professor, University of Cincinnati Medical Center, Cincinnati, OH
Ali E. Denktas, MD, FACC—Assistant Professor, Baylor College of Medicine, Houston, TX
Lloyd W. Klein, MD, FACC—Professor of Medicine, Melrose Park, IL
Frederick G. Kushner, MD, FACC—Clinical Professor, Tulane University Medical Center, Medical Director, Heart Clinic of Louisiana, Marrero, LA
Glenn N. Levine, MD, FACC—Professor, Baylor College of Medicine, Cardiology, Pearland, TX
David Joel Maron, MD, FACC—Professor of Medicine and Emergency Medicine, Stanford University School of Medicine, Stanford, CA
James B. McClurken, MD, FACC—Director of Thoracic Surgery, Professor of Surgery Emeritus, Temple University, School of Medicine, Richard A Reif Heart Institute, Doylestown Hospital, Doylestown, PA
Robert N. Piana, MD, FACC—Professor of Medicine, Cardiology, Vanderbilt University Medical Center, Nashville, TN
John A. Spertus, M.D, MPH, FACC—Adjunct Professor of Medicine, Washington University School of Medicine, St. Louis, MO
Raymond F. Stainback, MD, FACC—Medical Director, Non-Invasive Cardiology Texas Heart Institute at Baylor St. Luke's Medical Center, Houston, TX
Robert C. Stoler, MD, FACC—Director of Cardiac Catheterization Laboratory, Cardiology Consultants of Texas, Dallas, TX
Todd C. Villines, MD, FACC—Co-Director of Cardiovascular Computed Tomography and Assistant Chief, Cardiology Service at Walter Reed Army Medical Center, Rockville, MD
David H. Wiener, MD, FACC—Professor of Medicine, Jefferson Medical College, Jefferson Heart Institute, Philadelphia, PA
ACC Appropriate Use Criteria Task Force
John U. Doherty, MD, FACC, FAHA—Co-Chair, AUC Task Force, Professor of Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA
Gregory J. Dehmer, MD, MACC—Co-Chair, AUC Task Force, Medical Director, Cardiovascular Services, Central Texas Division, Baylor Scott & White Health, Temple, TX
Steven R. Bailey, MD, FACC, FSCAI, FAHA—Chair, Division of Cardiology, Professor of Medicine and Radiology, Janey Briscoe Distinguished Chair, University of Texas Health Sciences Center, San Antonio, TX
Nicole M. Bhave, MD, FACC—Clinical Assistant Professor, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Cardiovascular Center, Ann Arbor, MI
Alan S. Brown, MD, FACC—Medical Director, Midwest Heart Disease Prevention Center, Advocate Lutheran General Hospital, Director, Division of Cardiology, Park Ridge, IL
Stacie L. Daugherty, MD, FACC—Associate Professor, Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Denver, CO
Milind Y. Desai, MBBS, FACC—Associate Director, Clinical Investigations Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
Claire S. Duvernoy, MD, FACC—Cardiology Section Chief, Division of Cardiology, University of Michigan Health System, Ann Arbor, MI
Linda D. Gillam, MD, FACC—Chair, Department of Cardiovascular Medicine, Morristown Medical Center, Morristown, NJ
Robert C. Hendel, MD, FACC, FAHA—Director of Cardiac Imaging and Outpatient Services, Division of Cardiology, Miami University School of Medicine, Miami, FL
Christopher M. Kramer, MD, FACC, FAHA—Former Co-Chair, AUC Task Force, Ruth C. Heede Professor of Cardiology & Radiology, and Director, Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA
Bruce D. Lindsay, MD, FACC—Professor of Cardiology, Cleveland Clinic Foundation of Cardiovascular Medicine, Cleveland, OH
Warren J. Manning, MD, FACC—Professor of Medicine and Radiology, Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA
Manesh R. Patel, MD, FACC, FAHA—Former Chair, AUC Task Force, Assistant Professor of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC
Ritu Sachdeva, MBBS, FACC—Associate Professor, Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Children’s Health Care of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA
L. Samuel Wann, MD, MACC—Staff Cardiologist, Columbia St. Mary's Healthcare, Milwaukee, WI
David E. Winchester, MD, FACC—Assistant Professor of Medicine, University of Florida, Division of Cardiology, Gainesville, FL
Joseph M. Allen, MA—Team Leader, Clinical Policy and Pathways, American College of Cardiology, Washington, DC
Appendix B Relationships With Industry (RWI) and Other Entities
The College and its partnering organizations rigorously avoid any actual, perceived, or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the rating panel. Specifically, all panelists are asked to provide disclosure statements of all relationships that might be perceived as real or potential conflicts of interest. These statements were reviewed by the Appropriate Use Criteria Task Force, discussed with all members of the rating panel at the face-to-face meeting, and updated and reviewed as necessary. The following is a table of relevant disclosures by the rating panel and oversight working group members. In addition, to ensure complete transparency, a full list of disclosure information—including relationships not pertinent to this document—is available in the Online Appendix.
Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: Members of the Writing Group, Rating Panel, Indication Reviewers, and AUC Task Force—Relationships With Industry and Other Entities (Relevant)
↵∗ Society for Cardiovascular Angiography and Interventions Representative.
↵† Society of Thoracic Surgeons Representative.
↵‡ American College of Cardiology Representative.
↵§ American Heart Association Representative.
↵‖ Society of Thoracic Surgeons Representative.
↵¶ American Association for Thoracic Surgery Representative.
↵# American Society of Echocardiography Representative.
↵∗∗ American Society of Nuclear Cardiology Representative.
↵†† Former Task Force member, current member during the writing effort.
↵‡‡ Former Task Force Co-Chair, current Co-Chair during the writing effort.
↵§§ Former Task Force Chair, current Chair during the writing effort.
This document was approved by the American College of Cardiology Board of Trustees in October 2016.
The American College of Cardiology requests that this document be cited as follows: Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, Smith PK. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 appropriate use criteria for coronary revascularization in patients with acute coronary syndromes: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2017;69:570–91.
This document has been reprinted in Catheterization and Cardiovascular Interventions and the Journal of Nuclear Cardiology.
Copies: This document is available on the World Wide Web site of the American College of Cardiology (www.acc.org). For copies of this document, please contact Elsevier Reprint Department, fax (212) 633-3820 or e-mail .
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Please contact.
- American College of Cardiology Foundation
- Patel M.R.,
- Dehmer G.J.,
- Hirshfeld J.W.,
- Smith P.K.,
- Spertus J.A.
- O'Gara P.T.,
- Kushner F.G.,
- Ascheim D.D.,
- et al.
- Jneid H.,
- Anderson J.L.,
- Wright R.S.,
- et al.
- Fihn S.D.,
- Blankenship J.C.,
- Alexander K.P.,
- et al.
- Levine G.N.,
- O'Gara P.T.,
- Bates E.R.,
- et al.
- Engstrom T.,
- Kelbaek H.,
- Helqvist S.,
- et al.
- Gershlick A.H.,
- Khan J.N.,
- Kelly D.J.,
- et al.
- Hendel R.C.,
- Patel M.R.,
- Allen J.M.,
- et al.
- Smith S.C. Jr..,
- Allen J.,
- Blair S.N.,
- et al.
- Pearson T.A.,
- Blair S.N.,
- Daniels S.R.,
- et al.
- Buse J.B.,
- Ginsberg H.N.,
- Bakris G.L.,
- et al.
- Adult Treatment Panel III
- Harold J.G.,
- Bass T.A.,
- Bashore T.M.,
- et al.
- Hillis L.D.,
- Smith P.,
- Anderson J.,
- et al.
- Levine G.N.,
- Bates E.R.,
- Blankenship J.C.,
- et al.
- Amsterdam E.A.,
- Wenger N.K.,
- Brindis R.G.,
- et al.
- ↵TIMI Study Group. Available at: http://www.timi.org. Accessed March 15, 2011.
- Lin G.A.,
- Fagerlin A.
- Ting H.H.,
- Brito J.P.,
- Montori V.M.
- Buchanan A.
- Rating Panel
- Appropriate Use Criteria Task Force
- Table of Contents
- 1 Introduction
- 2 Methods
- 3 Assumptions
- 4 Definitions
- 5 Abbreviations
- 6 Coronary Revascularization in Patients With ACS: AUC (By Indication)
- 7 Discussion
- ACC President and Staff
- Appendix A Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: Participants
- Appendix B Relationships With Industry (RWI) and Other Entities
- Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: Members of the Writing Group, Rating Panel, Indication Reviewers, and AUC Task Force—Relationships With Industry and Other Entities (Relevant)