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CathPCI Registry March 14, 2017 4:00 pm – 5:30 pm Appropriate Use Criteria Session Presenters: Issam Moussa, MD, FACC, FSCAI Gregory J. Dehmer, MD, MACC, MSCAI, FACP, FAHA Melissa Nitta, MPH, BSN, RN Objectives: 1. 2. 3. 4. Identify the AUC methodology manuscripts Summarize the purpose of the AUC List the new AUC categories Recognize v5 AUC significant data elements Pre-Work: 1. Wolk, et al (2013). Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease. JACC Vol. 63;380-406 2. Patel, et al (2017). Appropriate Use Criteria for Coronary Revascularization in Patients with Acute Coronary Syndromes. JACC Vol. 69;570-91 3. Patel, et al (2017). Appropriate Use Criteria for Coronary Revascularization in Patients with Stable Ischemic Heart Disease (not published at time of support material generation; visit www.onlinejacc.org and search under Issues after March 10, 2017 to view online!) Notes/Outline: I. Why do we have Appropriate Use Criteria for Coronary Revascularization procedures? a. Cost b. Value c. Variation in PCI d. Quality CathPCI Registry Workshop March 14, 2017, 4:00 pm Page 1 e. Self-regulation f. II. A benchmark for PCI Utilization Documents that Affect Care a. Performance Measures b. Clinical Practice Guidelines c. Appropriate Use Criteria III. How the AUC evolved a. Changing terms b. Multimodality documents IV. The new AUC for Coronary Artery Revascularization a. Writing group b. Rating panel c. Influence of Clinical Trials d. New PCI/STEMI Guidelines Focused Update e. Appropriate Use Criteria for Acute Coronary Syndromes (STEMI, NSTEMI, Unstable Angina) f. V. Appropriate Use Criteria for Stable Ischemic Heart Disease Review of v5 data elements that support AUC mapping Frequently Used Terminology: Appropriate Use Criteria (AUC) – weigh the expected health benefit against the expected health risk for the procedure indication and are designed to be used as a tool by clinicians and patients when considering the use of PCI as a treatment option. Appropriate Care – PCI is viewed as being generally acceptable and a reasonable approach for the indication. The health benefits are understood to outweigh the procedural risks. However, a rating of appropriate does not mandate that a procedure or revascularization strategy be performed. 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. PCI is generally acceptable and may be a reasonable approach for the patient and can be considered by the patient and provider. Rarely appropriate care – this rating 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 patients. There is CathPCI Registry Workshop March 14, 2017, 4:00 pm Page 2 a lack of clear benefit/risk advantage to patients with this indication the procedure is not generally acceptable and is not generally reasonable for the indication. Culprit Stenosis – the artery/stenosis responsible for the acute coronary syndrome Abbreviations AA = Antianginal ACS = Acute Coronary Syndrome AUC = Appropriate Use Criteria BB = Beta-blockers CABG = Coronary Artery Bypass Graft CAD = Coronary Artery Disease FFR = Fractional Flow Reserve IMA = Internal Mammary Artery IRA = Infarct-Related Artery LAD = Left Anterior Descending Coronary Artery LVEF = Left Ventricular Ejection Fraction PCI = Percutaneous Coronary Intervention SIHD = Stable Ischemic Heart Disease STEMI = ST-Segment Elevation Myocardial Infarction NSTEMI = Non-ST Segment Elevation Myocardial Infarction TIMI = Thrombolysis In Myocardial Infarction Severity of disease is defined as: Severe: 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. Intermediate: c. A ≥50% and <70% diameter narrowing of an epicardial stenosis made by visual assessment in the “worst view” angiographic projection. Action Items: Please complete the following activities after attending this session: 1. Gain familiarity with all Appropriate Use Criteria (AUC) source materials and circulate to clinical team 2. Review current documentation practices and evaluate opportunities for improvement in capturing new AUC concepts CathPCI Registry Workshop March 14, 2017, 4:00 pm Page 3 3. Join the monthly Registry Site Manager calls occurring the 3rd Thursday of every month for updates and discussions of the v5 dataset! The schedule is found on the ‘Education’ page and the dial-in information appears on the registry landing page prior to the call. 4. Watch the registry landing page for Announcements specific to the v5 upgrade 5. Monitor the Documents Home Page for pertinent v5 resources which will be posted/available when applied to the registry 6. Question(s)? Email [email protected] Resources: Wolk, et al (2013). Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease. JACC Vol. 63;380-406 Patel, et al (2017). Appropriate Use Criteria for Coronary Revascularization in Patients with Acute Coronary Syndromes. JACC Vol. 69;570-91 Patel, et al (2017). Appropriate Use Criteria for Coronary Revascularization in Patients with Stable Ischemic Heart Disease (not published at time of support material generation) CathPCI Registry Workshop March 14, 2017, 4:00 pm Page 4