Download Appropriate - CCC Symposium

Complex Coronary Valvular and Vascular Cases
(CCVVC) Symposium:
Interventional Cardiology Board Review Course
– Appropriate Use Criteria
Usman Baber, MD MS
Assistant Professor of Medicine
Icahn School of Medicine at Mount Sinai
New York, NY
Outline
1. Background/Definition of AUC
2. Mount Sinai Process/Results
3. Questions
ACCF/SCAI/STS/AATS/AHA/ASNC Appropriateness
Criteria for Coronary Revascularization
2009 – ACCF/SCAI/STS/AATS/AHA/ASNC Appropriateness Criteria for
Coronary Revascularization first created
2012 – Updated Appropriateness Criteria issued
Organizations involved in development:
•
The American College of Cardiology Foundation (ACCF)
•
Society for Cardiovascular Angiography and Interventions
•
Society of Thoracic Surgeons
•
American Association for Thoracic Surgery
•
Key specialty and subspecialty societies
(Patel, Dehmer et al. 2012)
Methodology
•
~180 clinical scenarios were developed to mimic common situations
encountered in everyday practice
•
Each scenario included information on:
- symptom status
- extent of medical therapy
- risk level as assessed by noninvasive testing
- coronary anatomy
•
Each scenario was scored by a separate technical panel
on a scale of 1 to 9:
Score 1-3 = Inappropriate
Score 4-6 = Uncertain
Score 7-9 = Appropriate
(Patel, Dehmer et al. 2012)
Meaning of appropriateness scores:
•
Appropriate:
Coronary revascularization is generally acceptable
It is a reasonable approach for the indication
It is likely to improve the patients' health outcomes or survival
•
Uncertain:
Coronary revascularization may be acceptable
It may be a reasonable approach for the indication
Uncertainty implies that more research and/or patient information is
needed to further classify the indication
•
Inappropriate:
Coronary revascularization is not generally acceptable
It is not a reasonable approach for the indication
It is unlikely to improve the patients' health outcomes or survival
(Patel, Dehmer et al. 2012)
General Principles
1. Anatomic disease with high prognostic weight (LM; prox LAD)
is generally appropriate for revascularization
2. Minimal CAD without optimal medical Rx or low-risk stress is
generally inappropriate
3. Acute coronary syndromes are usually appropriate
Are You Performing Appropriate Procedures?
PCI
performed
Data submission to
national/regional entity
New York State
NCDR CathPCI
Hospital/
Individual
Level Metrics
Aggregated
AUC Process at Mount Sinai: Use of EHR
CRS
EPIC
OUTCOMES
CRS + EPIC + Event adjudication + Standardized data elements + Clinical outcomes
AUC Metrics
Patients without Acute Coronary Syndrome: Proportion
of evaluated PCI procedures that were appropriate
100%
80%
69.23%
56.21%
60%
50.17%
40%
20%
0%
US Median R4Q (ALL
HOSPITALS)
US Vol Group R4Q
Mount Sinai R4Q
Proportion of PCI procedures that were evaluated as “Appropriate”, among patients without ACS,
meaning coronary revascularization is generally acceptable and is a reasonable approach for the
indication and is likely to improve the patients’ health outcomes or survival.
AUC Metrics
Patients without Acute Coronary Syndrome: Proportion
of evaluated PCI procedures that were inappropriate
20%
15%
13.22%
9.52%
10%
4.51%
5%
0%
US Median R4Q (All
Hospitals)
US Vol Group R4Q
Mount Sinai R4Q
Proportion of PCI procedures that were evaluated as “Inappropriate”, among patients
without ACS, meaning coronary revascularization is not generally acceptable and is not
a reasonable approach for the indication and is unlikely to improve the patients’ health
outcomes or survival.
AUC Metrics
Patients without Acute Coronary Syndrome: Proportion of
evaluated PCI procedures that were of uncertain appropriateness
40%
35%
32.79%
34.27%
30%
26.26%
25%
20%
15%
10%
5%
0%
US Median R4Q (All
Hospitals)
US Vol Group R4Q
Mount Sinai R4Q
Proportion of PCI procedures that were evaluated as “Uncertain”, among patients without ACS, meaning
coronary revascularization may be acceptable and may be a reasonable approach for the indication.
However, some degree of uncertainty exists, implying that more research and/or patient information is
needed to determine whether the procedure would improve patients’ health outcomes or survival.
The purpose of developing the Appropriate Use
Criteria for Coronary Revascularization was:
A.
To eliminate the difficulty and uncertainty of clinical
decision making
B.
To replace the ACC/AHA guidelines
C.
To provide guidance for patients and clinicians for
judicious and rational use of PCI
D.
To provide a substitute for clinical judgment
The purpose of developing the Appropriate Use
Criteria for Coronary Revascularization was:
A.
B.
C.
D.
To eliminate the difficulty and uncertainty of clinical
decision making
To replace the ACC/AHA guidelines
To provide guidance for patients and clinicians
for judicious and rational use of PCI
To provide a substitute for clinical judgment
Patel, M. R., et al. (2009). "ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary
Revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force,
Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for
Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the
American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular
Computed Tomography." J Am Coll Cardiol 53(6): 530-553.
The indications for coronary revascularization
were developed taking into consideration:
A.
Extent of anatomic disease
B.
Clinical presentation
C.
Severity of angina
D.
Intensity of medical therapy
E.
Use of invasive hemodynamic assessment in selected scenarios
F.
All of the above variables were taken into consideration
The indications for coronary revascularization
were developed taking into consideration:
A.
Extent of anatomic disease
B.
Clinical presentation
C.
Severity of angina
D.
Intensity of medical therapy
E.
Use of invasive hemodynamic assessment in selected scenarios
F.
All of the above variables were taken into consideration
Patel, M. R., et al. (2009). "ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a
report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular
Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart
Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the
Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography." J Am Coll Cardiol 53(6): 530553.
Maximal anti-ischemic medical therapy per the
AUC is defined as:
A. Use of at least 2 anti-anginal medications at maximal
doses
B. Use of at least 2 classes of anti-anginal therapies
C. Use of at least 2 anti-anginal medications at any dose for
2 weeks or more
D. Use of at least 2 classes of anti-anginal therapies for 2
weeks or more
Maximal anti-ischemic medical therapy per the
AUC is defined as:
A.
Use of at least 2 anti-anginal medications at maximal doses
B.
Use of at least 2 classes of anti-anginal therapies
C.
Use of at least 2 anti-anginal medications at any dose for 2
weeks or more
D.
Use of at least 2 classes of anti-anginal therapies for 2 weeks
or more
Patel, M. R., et al. (2012). "ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: A report of the American College
of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic
Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography." The Journal of Thoracic and Cardiovascular
Surgery 143(4): 780-803.
High-risk stress test per the AUC is defined as:
A.
Cardiac mortality greater than 3% per year
B.
All-cause mortality greater than 5% per year
C.
MI, Revascularization or death greater than 5% per year
D.
Cardiac mortality greater than 2% per year
High-risk stress test per the AUC is defined as:
A.
Cardiac mortality greater than 3% per year
B.
All-cause mortality greater than 5% per year
C.
MI, Revascularization or death greater than 5% per year
D.
Cardiac mortality greater than 2% per year
Patel, M. R., et al. (2012). "ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for
coronary revascularization focused update: A report of the American College of Cardiology Foundation
Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of
Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society
of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography." The Journal of Thoracic and
Cardiovascular Surgery 143(4): 780-803.
Which of the following stress test findings is
considered intermediate risk by the AUC?
A.
Treadmill score of -11
B.
Multiple perfusion defects of moderate size
C.
Stress echocardiographic evidence of wall-motion
abnormality involving 2 segments
D.
Resting LVEF 30%
Which of the following stress test findings is
considered intermediate risk by the AUC?
A.
Treadmill score of -11
B.
Multiple perfusion defects of moderate size
C.
Stress echocardiographic evidence of wallmotion abnormality involving 2 segments
D.
Resting LVEF 30%
For a patient with no prior bypass surgery who has onevessel CAD involving the proximal LAD, CCS angina
class III, low-risk findings on noninvasive testing, and is
receiving maximal anti-ischemic medical therapy,
coronary revascularization is:
A.
B.
C.
D.
Inappropriate
Appropriate
Unable to Rate
Uncertain
For a patient with no prior bypass surgery who has
one-vessel CAD involving the proximal LAD, CCS
angina class III, low-risk findings on noninvasive
testing, and is receiving maximal anti-ischemic
medical therapy, coronary revascularization is:
A.
B.
C.
D.
Inappropriate
Appropriate
Unable to rate
Uncertain
Patel, M. R., et al. (2012). "ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused
update: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography
and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of
Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography." The Journal of Thoracic and Cardiovascular Surgery 143(4): 780803.
Table 2, # 31
A patient has had STEMI with successful treatment of the culprit
artery by primary PCI, is currently asymptomatic with no HF, no
evidence of recurrent or provokable ischemia, no unstable
ventricular arrhythmias during index hospitalization, and normal
LVEF.
During index hospitalization, revascularization of a non-infarct
related artery in this patient is:
A.
B.
C.
D.
Appropriate
Inappropriate
Uncertain
Not Rated
A patient has had STEMI with successful treatment of the culprit
artery by primary PCI, is currently asymptomatic with no HF, no
evidence of recurrent or provokable ischemia, no unstable
ventricular arrhythmias during index hospitalization, and normal
LVEF.
During index hospitalization, revascularization of a non-infarct
related artery in this patient is:
A.
B.
C.
D.
Appropriate
Inappropriate
Uncertain
Not Rated
Patel, M. R., et al. (2012). "ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update:
A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and
Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear
Cardiology, and the Society of Cardiovascular Computed Tomography." The Journal of Thoracic and Cardiovascular Surgery 143(4): 780-803.
Table 1, #7
For which of the following patients would
Coronary Revascularization be appropriate:
A.
A patient with prior Bypass surgery but no Acute Coronary Syndrome who
has CCS angina class II, has a lesion in a native coronary artery with no
bypass grafts, low-risk findings on noninvasive testing and normal LV systolic
function, and is receiving no anti-ischemic medical therapy
B.
A patient without prior bypass surgery who has chronic total occlusion of 1
major epicardial coronary artery without other coronary stenoses, has CCS
class III angina, high-risk criteria on noninvasive testing, and is receiving
maximal anti-ischemic medical therapy
C.
A patient with STEMI greater than 12 hours from symptom onset,
asymptomatic and with no hemodynamic or electrical instability
A.
All of these patients
B.
None of these patients
For which of the following patients would
Coronary Revascularization be appropriate:
A.
A patient with prior Bypass surgery but no Acute Coronary Syndrome who
has CCS angina class II, has a lesion in a native coronary artery with no
bypass grafts, low-risk findings on noninvasive testing and normal LV systolic
function, and is receiving no anti-ischemic medical therapy
B.
A patient without prior bypass surgery who has chronic total occlusion
of 1 major epicardial coronary artery without other coronary stenoses,
has CCS class III angina, high-risk criteria on noninvasive testing, and
is receiving maximal anti-ischemic medical therapy
C.
A patient with STEMI greater than 12 hours from symptom onset,
asymptomatic and with no hemodynamic or electrical instability
D.
All of these patients
E.
None of these patients
Patel, M. R., et al. (2012). "ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update:
A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions,
Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the
Society of Cardiovascular Computed Tomography." The Journal of Thoracic and Cardiovascular Surgery 143(4): 780-803.
Table 3, # 56
Table 2, # 29
Table 1, #3
For a patient with no prior bypass surgery who has left
main stenosis, the appropriateness of Coronary
Revascularization is:
A.
Uncertain
B.
Appropriate only with CCS Angina Class III or IV
C.
Appropriate regardless of CCS Angina Class
D.
Inappropriate regardless of CCS Angina Class
For a patient with no prior bypass surgery who
has left main stenosis, the appropriateness of
Coronary Revascularization is:
A.
Uncertain
B.
Appropriate only with CCS Angina Class III or IV
C.
Appropriate regardless of CCS Angina Class
D.
Inappropriate regardless of CCS Angina Class
Patel, M. R., et al. (2012). "ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary
revascularization focused update: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task
Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for
Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular
Computed Tomography." The Journal of Thoracic and Cardiovascular Surgery 143(4): 780-803.
Table 2, # 49
For a patient with no prior bypass surgery who has left
main stenosis, Coronary Revascularization with PCI is:
A.
Appropriate with isolated LM stenosis
B.
Appropriate with additional, intermediate CAD burden
C.
Inappropriate with additional, low CAD burden
D.
Uncertain with isolated LM stenosis
For a patient with no prior bypass surgery who
has left main stenosis, the appropriateness of
Coronary Revascularization is:
A.
Appropriate with isolated LM stenosis
B.
Appropriate with additional, intermediate CAD
burden
C.
Inappropriate with additional, low CAD burden
D.
Uncertain with isolated LM stenosis
Registry Data from the United States has
shown that the most common scenario for
inappropriate PCI involves:
A.
Patients with ACS
B.
Recanalization of a CTO
C.
Asymptomatic 2 vessel CAD without prox LAD
D.
Choices B and C
Registry Data from the United States has
shown that the most common scenario for
inappropriate PCI involves:
A.
Patients with ACS
B.
Recanalization of a CTO
C.
Asymptomatic 2 vessel CAD without prox LAD
D.
Choices B and C
Chan et al., JAMA 2011
In a patient with STEMI and evidence of
cardiogenic shock, is revascularization of ≥1
coronary arteries appropriate?
A.
Yes, it is appropriate
B.
No, it is not appropriate
C.
Uncertain
D.
It depends on the CCS angina class
In a patient with STEMI and evidence of
cardiogenic shock, is revascularization of
≥1 coronary arteries appropriate?
A.
B.
C.
D.
Yes, it is appropriate
No, it is not appropriate
Uncertain
It depends on the CCS angina class
Patel, M. R., et al. (2012). "ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary
revascularization focused update: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task
Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for
Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular
Computed Tomography." The Journal of Thoracic and Cardiovascular Surgery 143(4): 780-803.
Table 1, #13
A patient with prior bypass surgery and without ACS
has stenosis in the saphenous vein graft, high-risk
findings on noninvasive testing, and is receiving a course
of maximal anti-ischemic medical therapy.
Is Coronary Revascularization appropriate?
A.
B.
C.
D.
Appropriate only in the presence of angina
symptoms
Appropriate only with CCS class III or IV angina
Appropriate for all CCS angina classes
Uncertain for all CCS angina classes
A patient with prior bypass surgery and without ACS
has stenosis in the saphenous vein graft, high-risk
findings on noninvasive testing, and is receiving a
course of maximal anti-ischemic medical therapy. Is
Coronary Revascularization appropriate?
A.
B.
C.
D.
Appropriate only in the presence of angina
symptoms
Appropriate only with CCS class III or IV angina
Appropriate for all CCS angina classes
Uncertain for all CCS angina classes
Patel, M. R., et al. (2012). "ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: A report of
the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic
Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular
Computed Tomography." The Journal of Thoracic and Cardiovascular Surgery 143(4): 780-803.
Table 3, # 55