Download Abstract C-062 - Society for Cardiovascular Angiography and

The Society for Cardiovascular Angiography and Interventions
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ID: C-062
Session Title/Time/Location:
Poster Session C/Thursday, May 29, 2014, 12:00 pm-3:00 pm (Pacific Time)/Exhibition Hall
Utility of a Real-Time Appropriate Use Criteria Decision
Support Tool for Percutaneous Coronary Interventions in
Non-Acute Coronary Syndrome
Category: Quality Improvement
Authors: Stuart Chen, Beth Israel Deaconess Medical Center/Harvard Medical School, United
States; Kalon K.L. Ho, Beth Israel Deaconess Medical Center/Harvard Medical School, United
States; Stephen Gannon, Beth Israel Deaconess Medical Center/Harvard Medical School,
United States; Braghadheeswar Thyagarajan, Beth Israel Deaconess Medical Center/Harvard
Medical School, United States; Anjan K Chakrabarti, Beth Israel Deaconess Medical
Center/Harvard Medical School, United States; Brian Potter, Beth Israel Deaconess Medical
Center/Harvard Medical School, United States; Anand Singla, Beth Israel Deaconess Medical
Center/Harvard Medical School, United States; Bryan Piccirillo, Beth Israel Deaconess Medical
Center/Harvard Medical School, United States; Christopher Meduri, Beth Israel Deaconess
Medical Center/Harvard Medical School, United States; Donald Cutlip, Beth Israel Deaconess
Medical Center/Harvard Medical School, United States
Background: Continued advances in cardiac revascularization techniques, along with rising
healthcare costs, potential misuse of invasive coronary procedures and a movement towards
reimbursement based on processes of care, have spurred significant interest in measuring
adherence to defined standards for appropriateness of interventions performed in the cardiac
catheterization laboratory. Use of the online Society for Cardiovascular Angiography and
Interventions (SCAI) Appropriate Use Criteria (AUC) application (http://nacs.scai-qit.org/)
permits auditing of real-time determination of the appropriateness of percutaneous coronary
intervention (PCI) during elective, non-acute coronary syndrome (non-ACS) procedures.
Methods: All patients undergoing diagnostic coronary angiography for non-ACS indications at
a single center were prospectively evaluated pre-procedure by entry of their Canadian
Cardiovascular Society (CCS) angina class, degree of anti-ischemic medical therapy, presence
and severity of stress test findings, and prior CABG history into the online SCAI AUC calculator.
The resultant worksheet outlining the rated scenarios of angiographic findings and their
corresponding levels of appropriateness (appropriate, inappropriate, uncertain) was posted for
each case. Patients undergoing subsequent PCI were included in this study and the
appropriateness of their PCI scored using the worksheet based on the newly documented
coronary anatomy. A blinded angiographic review was then performed and the independent
audit assessment of disease severity (diameter stenosis ≥70% vs. <70%) was compared with
the severity documented by the operator. The proportions of appropriate, inappropriate, and
uncertain PCIs were tabulated before and after the angiographic audit. Certain scenarios not
categorized by the 2012 AUC were recorded as ‘not rated’.
Results: In 165 consecutive lesions undergoing PCI for non-ACS indications, 64% (n=105) were
rated ‘appropriate’, 27% (n=44) ‘uncertain’, 1% (n=2) ‘inappropriate’, and 8% (n=14) ‘not
rated’. The angiographic audit determined concordance with the operator in 149 lesions,
including 9 that were deemed <70% stenosis by the operator but had fractional flow reserve
(FFR) <0.80. The remaining 16 lesions were deemed <70% stenosis by the audit and did not
have FFR performed. Using the audited angiographic data, 60% (n=99) of PCIs were
‘appropriate’, 22% (n=37) were ‘uncertain, 11% (n=18) were ‘inappropriate’, and 7% (n=11)
‘not rated’ (see Figure 1). An audit of 300 elective cases is ongoing, with comparison of the
audited results against the AUC ratings for the same cases reported by the National
Cardiovascular Data Registry (NCDR) CathPCI Registry Dashboard.
Conclusions: Our pilot study shows that the SCAI AUC application is easy to use and permits
real-time evaluation of PCI appropriateness during elective procedures. The results highlight
the potential importance of angiographic review in auditing appropriateness of elective PCIs as
the number of appropriate and inappropriate PCIs may be overestimated and underestimated,
respectively. Prospective use of the SCAI AUC application is a valuable quality improvement
process for cardiac catheterization laboratories. The ongoing comparison of AUC ratings based
on independently audited angiographic findings with retrospective AUC reports from the NCDR
CathPCI Registry should provide valuable insight into the accuracy of AUC determinations using
large observational registries.
Author Disclosures:
1. Stuart Chen: This author has nothing to disclose.
2. Kalon K.L. Ho: 9 Disclosures are already on file with SCAI.
3. Stephen Gannon: This author has nothing to disclose.
4. Braghadheeswar Thyagarajan: This author has nothing to disclose.
5. Anjan K Chakrabarti: This author has nothing to disclose.
6. Brian Potter: This author has nothing to disclose.
7. Anand Singla: This author has nothing to disclose.
8. Bryan Piccirillo: This author has nothing to disclose.
9. Christopher Meduri: This author has nothing to disclose.
10. Donald Cutlip: 9 Research support paid to insitution: Medtronic, Boston Scientific, Abbott
Vascular.